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THE
¥E¥ YORK
MEDICAL JOUE
A
WEEKLY REVIEW OF MEDICINE.
EDITED BY
FRANK P . FOSTER, M.D.
VOLUME XLII.'
JULY JO DECEMBER, 1885, INCLUSIVE.
NEW YORK:
D. APTLETON AND COMPANY,
1, 3, S BOND STREET.
J 885.
Copyright, 1885.
By D. APPLETON AND COMPANY.
LIST OF CONTRIBUTORS TO VOLUME XLIL
{EXCLUSIVE OF ANONYMOUS CORRESPONDENTS).
ABERDEIN, ROBERT, M. D., Syracuse,
N. Y.
ALLEN, HARRISON", M. D., Philadel-
phia.
ANDREWS, JOSEPH A., M. D.
BACON, GORHAM, M. D.
BAKER, HENRY B., M. D., Lansing,
Mich.
BARUCH, SIMON, M. D.
BAUDUY, JEROME K., M. D., LL. D.,
St. Louis.
BLACK, J. R., M. D., Newark, O.
BLISS, H. D., M. D., Brooklyn.
BREDIN, STEPHEN, M.D., Franklin,
Pa.
BRINKMAN, ALBERT, M. D., Brook-
lyn.
BULL, CHARLES STEDMAN, M. D.
BURCHARD, T. HERRING, M. D.
BURKE, W. C, Jr., M. D., South Nor-
walk, Conn.
BURT, STEPHEN S., M. D.
BUSH, J. FOSTER, M. D., Boston.
BUXTON, DUDLEY W., M. D., London.
CARPENTER, WESLEY M., M. D.
CARROLL, ALFRED L., M. D., Albany.
COE, HENRY C, M. D., M. R. C. S.,
L R C P
COOK, A. B., M. D., Louisville, Ky.
CONWAY, JOHN R., Jr., M. D.
CORNING, J. LEONARD, M. D.
CRAIG, JAMES, M. D., Jersey City.
CURRIER, ANDREW F., M. D.
CURTIS, B. FARQUHAR, M.D.
CURTISS, ROMAINE J., M. D., Joliet,
111.
DELAVAN, D. BRYSON, M. D.
DENISON, CHARLES, M. D., Denver,
Col.
DENNIS, FREDERIC S., M. D.
DIX, TANDY L., M. D., Shelbyville, Ky.
DUANE, ALEXANDER, M.D.
DU BOIS, HENRY A., M. D., San Ra-
fael, Cal.
DUNSTER, EDWARD S., M. D., Ann
Arbor, Mich.
ECCLES. R. G., M. D., Brooklyn.
EDWARDS, LANDON B., M. D., Rich-
mond, Va.
ELLIOT, GEORGE T., M. D.
ELSNER, H. L., M. D., Syracuse, N. Y.
EMERSON. J. H., M. D.
EMERY, Z. T., M. D., Brooklyn.
FERNALD, F. G, M. D., Washington.
FOSTER, FRANK P., M. D.
FOWLER, GEORGE R., M.D., Brook-
lyn.
FRASER, E. P., M.D., Portland, Oregon.
GARLAND, G. M., M. D., Boston.
GARRIGUES, HENRY J., M. D.
GARST, J., M. D., North Brookfield,
Mass.
GERSTER, ARPAD G., M.D.
GITHENS, W. H. H, M. D., Philadelphia.
GLASGOW, WILLIAM C, M. D., St.
Louis.
GRANGER, REED B., M. D.
GRAUER, FRANK, M. D.
GRAY, LANDON CARTER, M. D.,
Brooklyn.
HALLECK, HENRY TUTHILL, M. D.,
Brooklyn.
HALSTED, WILLIAM S., M. D.
HAMMOND, GRyEME M., M. D.
HAMMOND, WILLIAM A., M.D.
HARDAWAY, W. A., M. D., St. Louis.
HAYNES, W. H., M. D.
HENRY, MORRIS II., M. D., LL. D.
HOLT, L. EMMETT, M. D.
HOOPER, FRANKLIN H., M. D., Bos-
ton.
HOWARD, W. T., M. D., Baltimore.
HOWE, LUCIEN, M. D., Buffalo.
HUBBARD, LEROY W., M. D.
HUGHES, W. E., M. D., Philndelphia.
HYDE, JOEL W , M.D., Brooklyn.
INGALS, E. FLETCHER, M.D., Chicago.
IVES, FRANK L., M. D.
JACKSON, GEORGE THOMAS, M.D.
JACOBI, ABRAHAM, M.D.
JACOBY, GEORGE W., M.D.
JARVIS, WILLIAM CHAPMAN, M. D.
JEWETT, CHARLES, M. D., Brooklyn.
JOHNSON, H. A.. M. IX, Chicago.
JONES, C. N. DIXON, M. D., Brooklyn.
KELSEY, CHARLES B., M. D.
KESSLER, ADOLPH, M. D.
KNIGHT, FREDERICK I., M. D., Bos-
ton.
KOLIPINSKI, L., M. D., Washington.
LESTER, ELIAS, M. D., Seneca Falls,
N. Y.
LEUF, A. H. P., M.D., Brooklyn.
LEWIS, E. A., M. D., Brooklyn.
LIELL, EDWARD N., M. D.
L1L1ENTHAL. S., M. D.
LINCOLN, R. P., M. D.
LLOYD, SAMUEL, M.D.
MACKENZIE, JOHN N., M. D., Balti-
more.
MARKOE, FRANCIS H., M. D.
MASON, LEWIS D., M. D., Brooklyn.
MATTISON, J. B., M. D., Brooklyn.
MAXSON, EDWIN R., M. D., LL. D.,
Syracuse, N. Y.
MEARS, J. EWING, M. D., Philadel-
M^LAURY. WILLIAM M., M. D.
MERZBACH, JOSEPH, M. D., Brooklyn.
MICHAEL, J. EDWIN, M. D., Baltimore.
MILLS. G. A.
MINOT, CHARLES SEDGWICK, M. D.,
Boston.
MITCHELL, C. PITFIELD, M. D., M. R.
C. S.
MONTGOMERY, LISTON H., M. D.,
Chicago.
MOORE, EDWIN W., M. D., Franklin,
Pa.
MOORE, W. OLIVER, M. D.
MORRISON, W. H., M.D., Philadelphia.
MOSUER, ELIZA M., M. D., Brooklyn.
NORTHRIDGE, WILLIAM A., M. D.
Brooklyn.
O'DWYER, JOSEPH, M.D.
PEABODY, GEORGE L., M. D.
PIFFARD, HENRY G., M. D.
PLATT, ISAAC H, M. D., Brooklyn.
POLK, WILLIAM MECKLENBURG,
M. D.
POORE, CHARLES T., M. D.
PORTER, WILLIAM H., M.D.
RANNEY, AMBROSE L., M. D.
READ, HENRY N., M. D., Brooklyn.
REAMY, THAD. A., M. D., Cincinnati.
REED, C. A. LEE, M. D., Cincinnati.
RICE, CLARENCE C, M. D.
ROBERTS, JOHN B., M. D., Philadel-
phia.
ROBERTS, MILTON JOSIAH, M. D.
ROBERTSON, J. W., M. D., Detroit.
ROBINSON, BEVERLEY, M. D.
ROOSA, D. B. ST. JOHN, M. D., LL. D.
RUSSELL, the Hon. W. H. H.
SALMON, D. E., D. V. M., Washington.
SEI BERT, A., M. D.
SEW ALL, HENRY, Ph. D., Ann Arbor,
Mich.
SEXTON, SAMUEL, M. D.
SIIATTUCK, F. C, M. D., Boston.
SHUFELDT, R. W., M.D., U. S. Army.
SHULTZ, R. G, M. D.
SI1URLY, E. L., M.D., Detroit.
SIMMONS, A. R., M. D., Ithaca, N. Y.
SKENE, A. J. C, M. D., Brooklyn.
SMITH, A. A., M. D.
SMITH, ANDREW II., M. D.
SMITH, AUGUSTINE.
SP HAGUE, G., M. D., Chicago.
SQUIBB, E. H, M. D., Brooklyn.
STERN BERG, GEORGE M., M. D., U. S.
Army.
STUB, ARNOLD, M. D., Brooklyn.
STURGIS, FREDERICK R., M. D.
SUTHERLAND, W. P., M. D., Stillwell,
III.
TAYLOR, JAMES B., M. D.
THAYER, WILLIAM HENRY, M. D.,
Brooklyn.
THOMAS, T. GAILLARD, M. D.
TURNER, S. S., M. D., U. S. Army.
VANCE, AP MORGAN, M. D., Louis-
ville.
WALLTAN, SAMUEL S., M. D., Bloom-
in gd ale, N. Y.
WESTBROOK, BENJAMIN F., M. D.,
■ Brooklyn.
WILCOX, REYNOLD W., M. D.
WILDER, BURT G., M. I)., Ithaca, N. Y.
WILLARD, DE F., M. D., Philadelphia.
WILLIAMS, HERBERT F., M.D., Brook-
lyn.
WILLTTS, MARY, M.D.. Philadelphia.
WILSON. J. C, M. D., Philadelphia.
WOOLLEY, D. M., M. D.. Brooklyn.
WRIGHT. J. WILLISTON, M. D.
WYETH, JOHN A., M.D.
YALE, LEROY MILTON, M. D.
LIST OF ILLUSTRATIONS IN VOLUME XLIL
A Dog Table 5
The Pnysieian's Handy Cabinet Battery. . . 29
Large Cabinet Battery 30
Improved Iloltz Static Machine (American Pattern) 31
Drawing the Indirect Spark from the Body of a Patient 31
Various Forms of Electrodes employed with a Static Machine 32
Morton's Spark Electrode 32
Curves of Closure Contractions in Direct Stimulation of the Muscles
in the Distribution of the Peroneal Nerve in the Leg 59
Ranney's Spring Electrode 60
Ranney's Diagnostic Key-board 60
Ranney's Diagnostic Key-board as applied in Actual Use 60
Erb's Electrode for the Examination of Farado-Cutaneous Sensi-
bility 63
Galvanic Battery 66
Zinc and Chloride-of-Silver Cells. Two Illustrations 66
Absolute Galvanometer 6"
Phthisis and Pneumonia in their Relation to Syphilis. Three Illus-
trations 117, 118
A New Uterine Applicator and Dressing Forceps 138
Electrode for Electrolysis 141
Electrode for Electrolysis 142
Piffard's Cautery Battery 143
PAOB
Instruments for Intubation of the Larynx 147
Unilateral Temporal Hemianopsia. Three Illustrations 151, 152
The Pathology of Acute and Chronic Coryza. Two Illustrations. 212, 213
An Intra-vaginal Cup Syringe 249
I Nasal Affections as a Cause of Phthisis. Ten Illustrations
261, 262, 263, 264, 292
Diagram of His's Embryo 397
Thomson's Second Ovum 397
Diagram to show the Formation of the Human Amnion 398
Ovum supposed to be from Fifteen to Eighteen Days Old 399
Embryo supposed to be from Fifteen to Eighteen Days Old 400
Fragment of the Chorion 400
A Case of Neglected Ear Disease 405
His's Embryo L 427
His's Embryo M 429
W. His's Embryo M 429
Eye Speculum. ... 483
Cases in Orthopaedic Surgery. Eight Illustrations 511-515
Hempstead Church 631
The Ruins of Hempstead Church 531
Jewett's Modification of Elliot's Obstetric Forceps 567
Spray Tube 603
Vulnar and Vaginal Enterocele. Four Illustrations 709,710
THE NEW YORK MEDICAL JOURNAL, Jitly 4, 1885.
#riomnl Communications.
ON THE USE OF GALVANISM
IN CHRONIC DISEASES OF THE PHARYNX *
By E. L. SHURLY, M. D.,
DETROIT.
You will doubtless remember that at the Congress of
1880 I presented a short paper calling attention to the use
of galvanism in the treatment of pharyngitis sicca. At that
time I had had but a limited experience with this agent in
such conditions, but since then I have used galvanism in a
number of cases with, I think, such good results as to justi-
fy me in again calling your attention to the subject. The
difficulties which I then narrated as attending the use of
electrodes in the pharynx can be much reduced through the
use of cocaine, and therefore this treatment is practicable for
almost any person. I believe it is very generally confessed
that our knowledge of the pathology and pathogenesis of
the chronic affections of the pharyngeal mucous membrane
is far from exact or complete.
Certain well-recognized features or symptoms, such as
habitual engorgement, hypersecretion, glandular enlarge-
ment with or without paucity or perversion of secretion,
constituting the local manifestations of many cases which
present themselves to us, and which, I am sorry to say,
puzzle us in the selection of the proper means for ameliora-
tion. That some of these conditions of the pharynx —
chronic engorgement, hypersecretion, etc. — are often only
local expressions of a derangement of the stomach, the in-
testinal canal, or possibly some more remote organ, is well
known and does not surprise us, since the anatomical and
physiological connection or relationship between these or-
gans and the pharynx is probably intimate. We also meet
with neuroses of the pharynx — hyperesthesia, spasm, par-
esthesia, etc. — which are dependent upon derangement
either of these same organs or the genito-urinary or mental
apparatus, all of which require little or no local treatment.
But, besides this class of cases, there are certain organic
lesions of the pharyngeal mucous membrane which can not
be traced to any particular disorder of the neighboring or
remote organs or glands, which are characterized by changes
such as glandular hypertrophy, general hyperplasia, hyper-
secretion with or without extraordinary epithelial develop
ment, atrophy with diminished secretion, etc. It is to these
that I wish particularly to call your attention.
They constitute changes which may be regarded as tro
phic, and which, however inexplicable, must be regarded as
distinct local disorders. In my mind there has long been a
conviction that glandular hypertrophy and atrophy with or
without persistent extra secretion and without much organic
change in the membrane are due to a perversion of function
of the nervous apparatus distributed to the pharyngeal re
gion. It does seem impossible that the mere mechanical
effect of infiltration or interstitial deposit can account alto
* Read before the American Laryngological Association, June 24
1885.
gether for the wasting of the membrane. Likewise does it
seem impossible that the disagreeable symptoms of typical
pharyngeal disease, even when associated with thickening
or wasting of the glandule, etc., can be fairly attributed to
ordinary inflammation and its consequences, because we
often find people with throats presenting such appearances,
even to a considerable degree, who do not complain of in-
convenience nor show disturbance of the nutrition of the
part. Therefore it would seem probable that some of these
conditions must be at least regarded as distinct local disease
having for its origin some nutritive abnormality antecedent
to the inflammatory changes ; and may we not find a possi-
ble explanation in the supposition of metabolic derange-
ment through a disordered trophic function of the hypo-
glossal, pneumogastric, or sympathetic nerves ?
Considering the analogy between the functions of the
hypoglossal and the fifth, and the facts already demon-
strated regarding the trophic influence of the latter nerve,
this hypothesis would seem to gain support. However, the
light of further investigation may show that, instead of the
hypoglossal, either the pneumogastric or sympathetic, or
both, may be the reigning influence in the nutritive changes
of the pharyngeal mucous membrane ; but, whichever may
be the case, the result is the same. Acting upon the fore-
going theory, I have been led into the employment of dif-
ferent agents for local use, with a view of counteracting this
perverted trophic influence ; but, of all the agents used, I
think I have obtained more lasting effects from galvanism.
Many of the local stimulant applications, while certainly
valuable, are soon followed by a reaction which shows the
excitement to have been only of short duration and in no
wise of vital character. But with the galvanic current I
think I have found much more enduring effects ; for example,
the mucous membrane remains in many cases of a vivid
color and bathed in a quite fluid secretion for a number of
hours after the application, and, moreover, leaves a sensation
of heat and pliability — in cases of atrophy — which the pa-
tients describe as slightly exhilarating. The effect of the
application is sometimes felt in adjacent parts — such as the
cervical region. One of my patients states that the sensa-
tion of heat always remains in his throat for about forty-
eight hours. After a few applications the sense of dryness
and the collection of desiccated secretion in and about the
naso-pharynx, which occur in the severer forms of chronic
naso-pharyngeal disease, very sensibly lessen. In cases of
engorgement accompanied by hypersecretion the result of
this treatment has been quite efficient. Also in distinctly
neurotic conditions — such as paresthesia — I have had good
effects from galvanism.
I usually pursue the following method, viz. : First wash
off the surface of the membrane, by means of a spray or
posterior douche, with a solution of common salt or other
appropriate fluid ; then apply a four-per-cent. solution of
cocaine hydrochlorate, and, after an interval of about five
minutes, apply the electrodes (which 1 here show you), one
through the nasal passage and the other to the posterior
and lateral wall of the pharynx, moving them both rapidly
but gently over the surface, being careful to keep them
HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX. [N. Y. Med Jo
2
closely applied. I generally connect the electrodes with
two cells (increasing to four or five) of a battery composed
of the improved Leclanche cells. The electrodes are not
covered, but naked, unless it is desired — as in cases purely
nervous — to apply one electrode to the side of the neck,
when that is covered. Gagging and muscular movements
require the removal of the instruments, after a few seconds,
for a short period of repose, when they are reapplied per-
haps four or five times, according to the tolerance of the
patient and the sensible effect produced. The seance may
be repeated two or three times a week, as may seem advis-
able. I have experienced the greatest difficulty from the
intolerance of the parts in question to the manipulation,
but, as before mentioned, the use of cocaine has afforded, in
the majority of cases, the desired tolerance. However, as
might be expected, the drug to a certain extent antagonizes
the effect of the galvanic application, and must be compen-
sated for either by a longer or more frequent manipulation.
In some cases one thorough treatment a week will prove
sufficient.
Of course, it is not expected that this, any more than
any other, plan of treatment will restore already destroyed
tissue, but that it is competent to arrest those metamorpho-
ses which finally result in either the loss of glandular as
well as other elements of the membrane, or the substitution
of adventitious for the normal tissues, I firmly believe, in
view of my experience with it. The period of time re-
quired for reaching permanent results will vary, of course,
according to the kind of case and the state of chronicity
presented. The only therapeutic theory which I have to
offer is a very commonplace one, viz., the restoration of the
nutrition and normal secretion of the parts through the
direct application of the electric fluid to the terminal nerve-
filaments.
THE RESPIRATORY FUNCTION OF TILE
HUMAN LARYNX*
FROM EXPERIMENTAL STUDIES IN THE PHYSIOLOGICAL
LABORATORY OF HARVARD UNIVERSITY.
By FRANKLIN H. HOOPER, M. D.,
BOSTON.
The human larynx has two principal functions : (a) The
respiratory, (b) the phonatory. They are mentioned in the
order of their importance, for, while the muscles concerned
in phonation, supplemented by other constrictors, are
charged with the additional duty of closing the laryngeal
aperture to protect the air-passages from the entrance of
foreign bodies, yet it must be conceded that, whether em-
ployed in phonation — marvelous as this function is — or
brought into action to exclude some foreign substance, the
part performed by these constrictors is entirely subordinate
to that of the respiratory muscle of the larynx, whose office
is to hold the glottis open in order to insure an uninter-
rupted passage of air to and from the lungs. f Nevertheless,
* Read before the American Laryngological Association, June 24,
1885.
f The intrinsic laryngeal muscles are in pairs except one, the trans-
verse arytenoid. The posterior crico-arytenoids are the respiratory
it is this important muscle which is not only the chief
among the intrinsic muscles of the larynx, but also one of
the most essential of the whole body — a muscle, be it re-
membered, of organic life * — that many writers would have
us helieve has a special tendency to succumb to disease.
Gerhardt, in his well-known paper,f was perhaps the first to
speak of unilateral paralysis of this muscle (the posterior
crico-arytenoid) as the most innocent of all forms of laryn-
geal paralyses. He points out that neither the voice nor
the respiration is impaired in such lesions. Schech J writes
in the same strain, and believes that, as the voice and quiet
respiration are not affected in these instances, this circum-
stance accounts for their having escaped more frequent men-
tion. Two prominent exponents of this theory (Rosenbach *
and Semon ||) have stated that in central or peripheral affec-
tions where the filaments of the recurrent laryngeal nerve are
compressed, the fibers innervating the respiratory muscle are
earlier affected than those going to the phonatory muscles ;
that this is in accordance with the well-ascertained fact that,
in central or peripheral nerve lesions, the extensor muscles A
are more readily paralyzed than the flexors; that there is a
" proclivity of the adductor fibers of the recurrent laryngeal
nerve to become affected sooner than the adductor fibers, or
even exclusively, in cases of undoubted central or peripheral
injury, or disease of the roots or trunks of the pneumogas-
tric, spinal accessory, or recurrent nerves." Another au-
thor Q has recently gone so far as to say that the vul-
nerability of these a&ductor fibers is a fact upon which all
observers are now agreed.
We hazard the opinion, notwithstanding, that if we
investigate this complicated subject from a somewhat differ-
ent point of view — one not strictly clinical — we may dis-
cover certain reasons why one should not subscribe uncon-
ditionally to this conception of the pathology of laryngeal
neuroses. We propose, therefore, to inquire into the truth
of this problem purely from an anatomical, physiological,
muscles. The phonatory muscles, which, like the respiratory muscles,
are attached to the arytenoid cartilages, are the internal thyroaryte-
noids, the lateral crico-arytenoids, and the transverse arytenoid. These
phonatory muscles are, when it is necessary, brought into action solely
to close the glottis and not for the purpose of phonation. Under these
circumstances they are supplemented by the muscles which compose
the aryteno-epiglottidean folds, and which, together with certain other
muscular fasciculi, may be classed as the sphincter group — the con-
strictor vestibuli laryngis. The thyro-cricoids are also phonatory mus-
cles; but with these, on account of their anatomical situation, we have
nothing to do in this paper.
* By this expression we refer to the normal automatic character of
the muscular action, and not to the microscopic structure of the muscle
itself.
f " Studien u. Beobachtungen iiber Kehlkopflahmung," Virchow's
"Archiv," vol. xxvii, p. 88, 1863.
$ " Experimented Untersuchungen iiber die Funktionen der Ner-
ven und Muskeln des Kehlkopfes," " Zeitsch. f. Biologie," Band ix, p.
258, 1873.
* "Bresl. arztl. Zeitschr.," Nos. 2-3, 1880; "Berlin, klin. Wochen-
schr.," No. 11, 1884; Virchow's "Archiv," Band 99, 1885.
I Mackenzie, " Diseases of the Throat and Nose," German edition,
1880 ; " Arch, of Laryngology," vol. ii, No. 3, 1881 ; " Berlin, klin.
Wochenschr.," Nos. 46-49, 1883; Ibid., No. 22, 1884.
A To this assumption that the posterior crico-arytenoid muscles are
extensors we shall recur.
() Gottstein, "Die Krankheiten des Kehlkopfes," p. 192, Wien, 1884.
July 4, 1885.] HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX.
3
and experimental standpoint. This being, then, in no sense,
a clinical paper, clinical evidence will not be offered, al-
though the writer's experience is far from being in accord
with the dictum that the nerve filaments which preside over
the most useful and important function of the larynx should
be especially prone to have that function arrested. The
superior laryngeal nerve, and the median laryngeal, recently
described by Exner,* need not in this study concern us.
The only other nerve, as far as we know to-day, going to
the intrinsic muscles of the larynx is the inferior or re-
current laryngeal. This nerve, according to our present
knowledge, is purely motor, \ and supplies all the intrinsic
laryngeal muscles except the longitudinal tensors, the thyro-
cricoids. It is an anatomical fact that it does not send off
any branches to these muscles until it has reached the
border of the cricoid cartilage. In its trunk, therefore, are
contained two sets of nerve fibers — the respiratory and the
phonatory — which must necessarily be strictly differentiated,
since they are destined for muscles which carry on two
separate and distinct functions. Now, where do these two
sets of nerve filaments come from ; is their origin as dis-
tinct as their function ; whence do they derive their sepa-
rate individualities ; which are relatively or numerically the
stronger ?
The sources from which nervous impulses for the larynx
may be received are the brain, the medulla oblongata, and
the spinal cord. The channels through which they may be
transmitted are the several motor nerves which join the
pneumogastric before the recurrent is given off, for we are
aware that from this point the recurrent proceeds to the
larynx without any branch or junction which is in any way
connected with the functions of that organ.
The experimental researches of Krause,J and the clinical
observations of Delavan,* justify the belief that there is a
center of motion for the larynx in the cortical substance of
the brain. It is also probable, as advanced by many, that the
several nerve filaments of the recurrent laryngeal may have
independent ganglionic centers somewhere in the brain or
medulla. Let us now follow down the real motor nerve tract
of the larynx from the medulla oblongata to the point of exit
of the recurrent laryngeal from the pneumogastric, and enu-
merate the different nerves which, from what we know posi-
tively or imagine hypothetically, may in any way influence
either of the functions of the larynx. In so doing we shall
adopt Longet's classification,! who divided them into the
direct and the indirect. Starting, then, at the medulla, we
name as the direct communications to the pneumogastric the
* " Die Innervation des Kehlkopfes," " Sitzungsb. d. k. Akademie
d. Wissenschaften," Band 89, Abth. iii, 1 u. 2 Heft, 1884.
\ We are aware that some have stated, but without giving experi-
mental data to substantiate the assertion, that the recurrent contains
sensory as well as motor fibers. We have not the space here to dwell
upon our own experiments to determine this point, but they justify our
remark that the recurrent is "purely motor."
t " Ueber die Beziehungen der Grosshirnrinde zu Kehlkopf und
Rachen," " Sitzungsberichte der kgl. preuss. Akad. der Wissensch. zu
Berlin," November, 1883.
* " On the Localization of the Cortical Motor Center of the Larynx,"
New York "Med. Record," February 14, 1885.
| " Traite de physiologie," vol. iii, p. 512, Paris, 1869.
internal branch of the spinal accessory, the facial, the hypo-
glossal, and the anterior branches of the first and second cer-
vical. The sympathetic may also furnish some direct fibers.
Under the head of indirect nerves — namely, those which join
the pneumogastric after having previously passed through
the sympathetic ganglia — we have all the branches of the
cervical below the second, and those of the dorsal nerves
situated, of course, above the point where the inferior
laryngeal shoots off from the pneumogastric to run its back-
ward course to the laryngeal muscles.
Our knowledge of the part played by these different
nerves in the performance of the functions of the larynx is
now, and, from the inherent difficulties of the problem, must
for a long time to come remain, unsatisfactory. The mass
of contradictory statements which one encounters in work-
ing up a subject in any way connected with the respiration,
and consequently with the pneumogastric nerve, is a suffi-
cient admonition against too positive and dogmatic asser-
tions. We approach this question, therefore, with reserve,
admitting, as we must, that a great part of the subject is yet
hardly beyond the confines of plausible conjecture.
It is pretty certain, however, as determined by the relia-
ble experiments of Bischoff,* Longet,| CI. Bernard,J and
Schech (loc. cit.), that the spinal accessory is a purely motor
nerve presiding over phonation, and having nothing to do
with the respiratory function of the larynx.* That there
may be other phonatory fibers in the pneumogastric we can
not gainsay. Now, how is the respiratory function inner-
vated ? Probably in many different and complex ways, in
accordance with the truth of the physiological law enunciated
by Longet.|| " Les moyens d'innervation propres a entretenir
le jeu d'un organe se multiplient en raison de son importance
physiologique." The posterior crico-arytenoids — the respi-
ratory muscles of the larynx — are paramount to all the rest
in physiological importance. From many sources they re-
* " Nervii accessorii Willisii anat. et physio].," Heidelberg, 1832.
f " Rech. expeVimen. sur les fonctions des mus. et des nerfs du lar-
ynx," etc., " Gaz. med. de Paris," 1841.
\ " Fonctions du nerf spinal," etc., " Le?ons sur la physiologie et la
pathologie du systeme nerveux," tome ii, Paris, 1858.
* Experimental physiology teaches us that if we cut the recurrent
nerves of a kitten or a puppy a few days old it immediately dies of
suffocation, which is not the case in old animals. The reason of this,
as originally explained by Legallois (" Experiences sur le principe de la
vie," Paris, 1812), is because in very young animals the cartilaginous
portion of the glottis is but slightly developed, and, the soft and yield-
ing parts not being held in position by the muscles, the laryngeal walls
are sucked together by the inspiratory effort, and the laryngeal aperture
is accordingly completely closed. CI. Bernard showed that section of
the spinal accessory in a kitten five weeks old was followed by aphonia,
but glottic respiration remained free. Two days afterward, the kitten
having remained well but voiceless, its recurrents were cut, when it in.
stantly died asphyxiated. He concludes from this that the pneumogas-
tric has a motor power independent of the spinal accessory which per-
mits the animal to breathe after the latter has been cut ; or, in other
words, the larynx is a vocal organ when excited by the spinal accessory,
and a respiratory organ when under the influence of the pneumogastric,
or more probably of other motor nerves associated with it. In certain
animals, as the chimpanzee, the internal branch of the spinal accessory
does not blend with the pneumogastric, but goes direct as a separate
nerve to the larynx.
| "Traite1 de phys.," vol. iii, p. 517, Paris, 1869.
4
HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX. [N. Y. Med. Jock.,
ceive an abundant nerve supply, which is to protect them
from disease, not to open up new channels by which harm
might come to them. With others we assume that there
are independent ganglia in the central nervous system which
are essentially their own. Being respiratory muscles, it is
more than probable that they may receive nerve force from
such respiratory nerves as the facial, the hypoglossal, and
the others already mentioned which run into the pneumo-
gastric. But in this connection we must quote Longet's
own words : * "Si la phonation, fonction secondaire et
accessoire, depend d'un nerf unique et disparait avec lui, la
dilatation respiratoire de la glotte, si essentielle, si indispen-
sable a la conservation du la vie, est sous la dependance ou
plutot sous la protection de nerfs multiples qui, dans cer-
tains limites, peuvent se suppleer les uns les autres. Aussi,
comine je l'ai deja fait remarquer, precisement avant de
donner origine aux recurrents qui animent les muscles crico-
arytenoidiens posterieurs, voit-on les pneumogastriques em-
prunter des fibres motrices a des nerfs qui to us intervien-
nent dans la respiration."
Summing up what has preceded, we can say that it all
points to the conclusion that the respiratory nerve filaments
contained in the recurrent laryngeal are derived from a
greater variety of sources than the phonatory.
We pass now to the experimental evidence bearing on
this point. It is a fact, familiar to all, that if anything
other than air finds its way into the larynx it produces, by
reflex action, a sudden closure of the glottis. It is equally
certain that, under normal conditions, the same contraction
of the laryngeal muscles may be instantly called forth by
direct stimulation of one or both of the recurrent nerves.
Now, it may with reason be asked, How is it that this con-
stricting action of the phonatory muscles is brought about
if it be true that the nerve fibers animating the dilators of
the glottis are the stronger and the more numerous ? Why
should we not get adduction of the vocal bands instead of
adduction on irritating the recurrent nerves ? The phona-
tory muscles are to the respiratory muscles as five to two,
and the closure of the glottis has always been ascribed to
the superior numerical strength of these constrictors. Yet
if we compare, bulk for bulk, the muscular fibers which
compose the five muscles of phonation with those of the two
respiratory muscles, we do not find that they are much, if
any, in excess of the latter, and we venture to think that
there is some other factor concerned in this phenomenon
apart from mere muscular force. It may be sought, per-
haps, in this important difference between the respiratory
and the phonatory function of the glottis — namely, that,
while the respiratory muscles are ever on the alert, holding
the glottis open during the entire healthy life of an indi-
vidual, in his waking as well as in his sleeping hours, the
phonatory muscles, on the other hand, are more dependent
upon the consciousness of the individual in order to respond
to any irritation. To explain : The phonatory function of
the phonatory muscles could, as far as life is concerned, be
dispensed with. Not so their constricting action with the
view of excluding the passage of foreign bodies to the lungs.
The constrictor muscles of the larynx are the sentinels who
* Loc. cii., p. 518.
guard the approach to these vital organs. But they cease
to act if the animal is in profound narcosis ; they are asleep,
so to speak, on their watch. A man in the condition known
as " dead drunk," lying, let us suppose, on his back witli his
mouth open, would offer no obstacle to prevent any living
insect that chanced his way from crawling in and out of his
mouth, or meandering round in his larynx a voionte, without
exciting reflex contraction of its muscles. The power of
ether, chloroform, and other amesthetics to impair the action
of these constrictors is too well known to need mention.
To carry this line of thought a little further, should we not
expect that, provided we could preserve the organic life of
an animal while its volition was at the same time completely
abolished — should we not expect, we ask, under these cir-
cumstances, to get a dilatation of the glottis on irritating the
recurrent nerves instead of a closure, for the posterior crico-
arytenoid muscles are muscles of organic life ? Indeed we
believe we should, and we submit the following experiments
in support of that belief. In performing the experiments
the writer has had the advantage of the collaboration of
Professor Henry P. Bowditch, to whom he would express
his thanks. With one exception, when a horse was the sub-
ject of an experiment, the animals used were dogs, the
proper selection of which for studies in experimental laryn-
gology is highly important. If a dog is either very old or
very large he is most unsatisfactory, if not absolutely worth-
less. He should be small and young ; the breed is of no
consequence. By arranging him in the following manner a
perfect view of the glottis can be obtained : After being
thoroughly etherized, he is secured on his back to a dog-
holder. A longitudinal incision is made in the skin cover-
ing the larynx, the fascia is divided, and the muscles are
drawn aside. The larynx and trachea are thereby brought
into view. One or both of the recurrent laryngeal nerves
may now be exposed. The mouth is held open by the up-
per jaw being firmly attached to the cross-bar of the dog-
holder, while a cord, tied round the lower jaw and secured
to any fixed point, keeps the jaws separated to the extent
desired. If the animal is placed before a window, the light
is transmitted through the wall of the trachea, illuminating
the glottis below, while the ordinary head reflector throws
the light in through the open mouth from above. The
tongue may be stretched up over the lower jaw and secured
to the skin by a thread. The epiglottis may be either tied
up by a string passed through its tip, or held up by an in-
strument suitably curved, having a long handle. The ac-
companying picture, taken from a photograph of a dog in
readiness for experimentation, may serve to make our de-
scription somewhat clearer. The animal is here shown
under conditions by which both recurrents could be stimu-
lated simultaneously.*
The phenomenon of an irritation applied to the recur-
rent laryngeal nerve producing an adduction of the corre-
sponding vocal band was first observed by accident. A
* For the sake of completeness of the figure, the primary coil is
represented as connected with a small bichromate cell, but in practice
it was connected with a Grove cell in a battery-closet. The induction
apparatus is the one described and figured in the " Proceedings of the
American Academy of Arts and Sciences," October 12, 1876.
July 4, 1885.] HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX.
5
small dog, of no particular breed, of an age estimated at
about ten months, as it still had some of its puppy teeth,
was being prepared for a different order of research. On
looking for the left recurrent nerve, it was not found in its
proper anatomical situation, but two small nerves were dis-
covered near by. As it was doubtful what these two
branches were, or whether they went to the larynx at all, a
shielded electrode was placed on the outer and larger nerve,
and, while the vocal bands were watched through the mouth,
it was irritated. The very unexpected result of the stimu-
lation was a forcible adduction of the left vocal band. Dr.
J. W. Warren, assistant in physiology, was requested to
come and witness this unusual sight. The ether sponge had
been removed from the dog since the beginning of the ex-
periment, and by the time Dr. Warren was ready to look at
the larynx the animal was somewhat out of its influence.*
At all events, on stimulating the nerve a second time, the
familiar closure of the glottis was manifested instead of the
dilatation so evident a few moments before. On the assump-
tion that the degree to which the animal was narcotized
might have something to do with these phenomena, a large
quantity of ether was again administered. After the dog
was profoundly under its influence, the nerve was irritated
a second time, when both Professor Bowditch and Dr. War-
ren observed the adduction of the vocal band, which was
more marked in proportion as the stimulation was more in-
tense. On removing the anaesthetic the dilatation became
less and less as the animal regained its consciousness, when
finally a contraction of the glottis supervened. The dif-
ferent stages in this experiment were readily followed by
watching the dog's vocal bands while, at the same time, the
recurrent nerve was irritated at intervals of a few moments.
Between extreme dilatation and forcible contraction, under
these circumstances, there seemed to be a neutral point, so
to speak, when the stimulation produced merely a vibratory
movement of the vocal band ; but this was soon succeeded
by an attempt at contraction, and this in turn passed into a
frank and decided closure of the glottis as the animal, as
before mentioned, came out of the effects of the ether.
Similar results followed stimulation of one or the other of
the divisions of the left recurrent nerve. These branches,
as was shown by subsequent dissection, and as you will see
on the specimen, united into one nerve fifteen millimetres
* Not in any of these experiments sufficiently to feel pain.
below the cricoid cartilage, and from this point to the larynx
it is a single nerve. The effects of irritation applied to the
right recurrent (which was single) agreed with those on the
left. Stimulation was effected by means of an
ordinary induction apparatus,* the intensity vary-
ing from 1 to 40. In general, however, in this
and in subsequent investigations on other dogs,
the intensity used was from 1 to 8, never over 10,
and generally about 3. The experiment many
times observed on this animal was repeated, with
confirmatory results, on eight different dogs. But
the extent and the force, it must be mentioned,
with which the vocal bands were aMucted differed
in different dogs. In five instances the arytenoid
cartilage was rotated outward so forcibly that the
vocal band lay flat against the wall of the larynx.
Moreover, in one case there was a marked adduc-
tion of the vocal band on the opposite side. In
other dogs a mixed movement was observed — that is,
the band approached the median line anteriorly, while
a simultaneous contraction of the posterior crico-aryte-
noid muscle took place posteriorly, which left, in the
respiratory portion of the glottis, a large triangular open-
ing, the glottic picture resembling an exaggerated form of
paralysis of the arytaenoidseus transversus muscle. These
phenomena were observed after the recurrent nerve had
been cut and its peripheral end stimulated as well as
when the nerve was intact. Usually when a young dog
is under ether the vocal bands are seen moving rhythmic-
ally and regularly with respiration. Occasionally, in this
condition of profound narcosis, we noticed that, although
the animal was breathing, the respiratory excursions of the
vocal bands had entirely ceased, the glottis remaining wide-
ly dilated. As soon as the respiratory movements had re-
commenced, irritation of the recurrent nerve was followed
by the usual adduction of the vocal band, an action we have
become accustomed to regard as the normal one, provided
the consciousness of an animal is completely abolished by
sulphuric ether. The most striking demonstration, how-
ever, of this dilatation of the glottis is obtained by placing
an electrode on each of the recurrent nerves and irritating
the two nerves at the same time. Both arytenoid cartilages
are now rotated simultaneously outward, the glottis is held
widely open during the stimulation, and the effect is one
not soon to be forgotten. Krause f has noticed the differ-
ence in the mobility of the vocal bands according as the
animal was more or less narcotized. Just in proportion as
consciousness was deadened, the adductors became sluggish.
We have repeatedly observed the same effect when the dog
was under morphine, chloral, or chloroform, but we failed
with all these agents to obtain the total abolition of the ac-
tion of the constrictors, on irritating the recurrent nerves,
* The electrical apparatus was the same as that used by the writer
in former experiments, to which the reader is referred for an explana-
tion of the terms employed. (See " Experimental Researches on the
Tension of the Vocal Bauds," " Trans, of the Amer. Laryngological As-
sociation," 1883, p. 121.)
f " Experimentelle Untersuchungen und Studien iiber Contractures
der Stimmbandmuskeln," Virchow's " Archiv," Band 98, 1884.
6
HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX. [N. Y. Med. Jodb.,
which is so marked when large quantities of ether, which
can be given with safety, are administered.
From the enormous development of the respiratory
laryngeal muscles of the horse we conjectured that their
contraction might be even more easily called forth than
that of a dog's. In this we were disappointed in the single
experiment we have performed on this animal. Chloroform
was the anaesthetic used. An incision was made in the
thyro-cricoid membrane, through which the finger was in-
serted and directed between the vocal bands. On irritating
the recurrent nerve the finger was tightly squeezed by the
contracting glottis. It is probable, however, that if ether
had been employed instead of chloroform, and the horse
thoroughly saturated with it, we should have felt the glottis
dilate and not contract. We were indebted to the Harvard
Veterinary College for this observation, and chloroform, for
reasons of convenience, is the only anaesthetic used in that
institution.
With a view to ascertaining whether certain fibers in
the recurrent were more vulnerable than others, we under-
took a series of observations of which the following may be
taken as the type: The nerve was exposed and a small
crystal of chromic acid was laid upon it. The electrode
being placed below this point, the nerve was irritated at in-
tervals while the chromic acid was working its slow destruc-
tion. In order to watch the effect upon the vocal band, the
dog was arranged as in the previous experiments. When
the animal was thoroughly etherized, the results did not dif-
fer materially from those already described. Stimulation
produced adduction of the vocal band. As the destructive
process of the acid progressed, the vocal band gradually be-
came completely paralyzed. But, even after the respiratory
movements of the vocal band had entirely ceased, irritation
was followed by an outward rotation of the arytenoid carti-
lage. This was only occasionally seen, and lasted but a mo-
ment, for, as soon as the conductivity of the nerve was
completely destroyed, stimulation naturally produced no
effect. We can only say that under these circumstances we
were able to produce an adduction of the vocal band as long
as any action at all was produced. How early or how late
in the destructive process the arfductor or phonatory fila-
ments were attacked we know not. Being few in number
(probably) as compared with the respiratory filaments, and
as ether, as we have shown, arrests so effectually their ac-
tion, we can not say here whether there was a " proclivity "
of either the one set or the other to become affected. We
simply demonstrated that the adductors held on to the last
moment, for, as long as a single nerve-fiber of any kind was
left intact, we got a contraction of the posterior crico-aryte-
noid muscle. When the destruction of the nerve was com-
plete, the vocal band stood motionless in the cadaveric posi-
tion.
In proceeding now to a new order of experiment, we
are able to record the endurance of the respiratory filaments
contained in the recurrent laryngeal nerve, while those des-
tined to supply the phonatory apparatus were altogether
unable to respond to stimulation. We took a small, young
dog, exposed the left recurrent nerve, and carefully passed
a thread through the middle of it. The two ends of the
thread were tied together in order to prevent its slipping
out, but no pressure was exerted on the nerve itself. The
object of the thread was simply to act as a foreign body. It
was hoped that inflammation might thereby be excited, and,
as the respiratory or phonatory fibers were the more readily
attacked, the effect of an irritation applied to the nerve be-
low the thread would be followed by certain derangements
of motion of the vocal band. After the thread had been
secured in the nerve, the parts were restored as nearly as
possible to their normal situations, and the incision in the
neck was sewed up. Inspection of the glottis showed that
both vocal bands were moving normally with respiration.
The following day the dog was again etherized and the
glottis examined. No apparent change had taken place
in either the appearance or natural mobility of the parts.
The nerve was not disturbed. Since the thread had been
introduced in it the nature of the dog had undergone a
change. From having been a confirmed howler he had be-
come a model of propriety. This happy improvement in
his disposition lasted until he was destroyed. The quieting
effect of a thread in the recurrent nerve has been noticed in
many dogs subsequently. At the end of a week, the dog
having been etherized and the glottis inspected on four dif-
ferent occasions, he was again placed under the anaesthetic
As soon as a cannula could be placed in the external jugu-
lar vein chloral was injected into it and the ether re-
moved. It is important to remember that in the following
experiments the animal was chloralized and not under
the influence of ether. A slight but evident change was
now observable in the vocal band corresponding to the-
nerve operated upon. Although the arytenoid cartilage of
this side appeared to move with respiration as naturally as
did the right cartilage, the anterior portion of the left vocal
band seemed to have lost its " tone " ; it did not come up
with the same "snap" on expiration as its fellow. On
opening the incision in the neck, the nerve was found im-
bedded in a considerable mass of inflammatory tissue, from
which it was impossible to separate it. After exposing the
nerve below this point, it was placed in a shielded electrode.
Irritation with an intensity varying from 1 to 10 produced
adduction of the left vocal band, and cessation of its respi-
ratory movements, the band remaining in the position of
deep inspiration as long as the stimulation was kept up.
On ceasing the irritation the respiratory movements went
on as before. The right vocal band was in no way influ-
enced when the left recurrent was stimulated with an inten-
sity not exceeding 10. When, however, a more powerful
stimulation (15) was employed, the right vocal band was
brought to the median line (phonatory position), while at
the same time the left band was pulled outward. W'e have,
then, here a double effect : adduction of the vocal band on
the healthy side, and a6duction on the side where some
alteration had taken place in the nerve fibers ; or, in other
words, the normal action of constriction of the right side
was manifested while the left band was a&ducted, owing to
the degeneration of the phonatory fibers, the respiratory
filaments remaining unharmed ; and, consequently, the respi-
ratory muscle alone responded to the stimulation. The
right vocal band was now paralyzed by section of the right
July 4, 1885.] HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX.
7
pneumogastric, the band coming to a standstill in the cadav-
eric position, or the position we are accustomed to see in
cases of " recurrent paralysis'." Stimulation applied to the
right recurrent resulted in a smart closure of the glottis,
effected by the right vocal band being brought forcibly
against its fellow, as well as by the contraction of the ary-
taenoidasus transversus, which approximated the two aryte-
noid cartilages. It could not be accurately determined
whether the anterior portion of the left band contracted or
not, as even a feeble irritation produced such a rapid and
complete closure of the laryngeal aperture. If the closure
of the left vocal band was brought into action, it was very
slight; it was evident that the closure of the glottis was
chiefly effected by the contraction of the constrictors on
the right side, and by the arytaenoidseus transversus muscle.
The electrode was again changed to the left recurrent below
the insertion of the thread. Stimulation was followed by
the same outward rotation of the left arytenoid cartilage as
was observed in the first experiment. There was also a
marked movement of the right arytenoid cartilage toward
its fellow, as if by the contraction of the arytaenoidaeus trans-
versus muscle. The action of this muscle was prominently
brought into play in the next experiment, when the periph-
eral end of the left recurrent was stimulated, after section of
the nerve below the thread. Both vocal bands were now
paralyzed and standing in the cadaveric position. All
avenues to the brain were thereby cut off except through
the anastomoses of the terminal branches of the recurrent
with those of the superior laryngeal, and, perhaps, also with
those from the pharyngeal plexus. Irritation of the periph-
eral end of the left recurrent produced both a contraction
of the left posterior crico-arytenoid and transverse arytenoid
muscles. That is, there was a distinct outward i-otation of
the vocal process of the left arytenoid cartilage, and an
approximation of both arytenoid cartilages at the same
time.
Positive as were the results of this series of experiments,
we lay no stress upon them. If they are of any worth, it
will be by suggesting to others some better method than
was here employed, for all our attempts to verify the ob-
servations have failed. Even when the thread had been
previously soaked in a one-per-cent. solution of chromic
acid it did not cause any material disturbance when intro-
duced through the nerve and retained there for many days.
The only change noticed was that, in some of the dogs, a
more powerful stimulation was required to produce a con-
traction of the vocal muscles through the nerve operated
upon than in the opposite healthy side.
CONCLUSIONS.
The principal fact herein demonstrated is, to our mind^
the power and the endurance of the posterior crico-arytenoid
muscles and of the nerves which supply them. We have
spoken of the theoretical reasons: (1) The physiological
importance of these muscles; (2) their belonging to organic
life; (3) their extensive nerve-supply, all of which would
tend to preserve their functional integrity. Moreover, if it
be true that there is a "proclivity" of the adductor fibers
to become diseased, and that unilateral paralysis of the ab-
ductor muscle is such a common and harmless lesion, should
we not expect, theoretically, that bilateral paralysis of this
muscle would occur more frequently ? Yet there can be no
dispute whatever that bilateral paralysis of the posterior
crico-arytenoids is a disease as rare as it is grave.
Now, with regard to these muscles being extensors, and,
like the extensors in other parts of the body — the forearm,
for instance — more liable to succumb to disease than the
flexors, we would ask this simple question : Why should the
terms " extension " and "flexion" be applied to the rota-
tion of the arytenoid cartilages ? The principal office of
the posterior crico-arytenoids is to maintain the respiratory
patency of the glottis. From the beginning to the end of
life they are in a state of semi-contraction — holding the
glottis open. They come, therefore, just as near being
flexors as extensors ; but, as a matter of fact, they are neither
the one nor the other in the ordinary acceptation of these
terms as applied to muscles of the general system. They
are respiratory muscles carrying on a special function. One
might as well speak of the movements of the pupil as exten-
sion and flexion, or compare the diastole of the heart to the
extension of the forearm, or its systole to the bending of
the little toes. Muscles are analogous as they discharge
analogous functions. We recognize no more analogy be-
tween the posterior crico-arytenoid muscles of the larynx
and the extensor communis digitorum of the forearm than
there is between "respiration" and "prehension." If we
wish to seek muscles that are analogous, let us turn to other
respiratory muscles and ask how they are affected by dis-
ease. In diffused, progressive diseases of the nervo-muscu-
lar system we know that of all muscles, except the heart
itself, those belonging to the respiratory system arc al-
ways the last to be attacked, and there is no valid reason
why the respiratory muscles of the larynx — either one or
both — should offer an exception to the rule, especially as
they are the most important of all.
We propose to investigate this subject from a clinical
aspect at some future date, when, perhaps, the positions
which immobile vocal bands assume may be sufficiently ex-
plained without attributing to a wise and conservative na-
ture a " proclivity " to attack one of the most vital muscles
of the human system.
DISCUSSION.
J. SoLis-ConEN. — It is a great honor to the American Laryn-
gological Association to have had this valuable paper read be-
fore it, and I believe it will be an historical paper. These ex-
periments will be subjected to criticism, and their verification
will become a matter of history in the controversy now existing
in the laryngological world as to the liability of these abductor
fibers to become diseased sooner than the adductors. The dog-
matism with which the assertion has been made seems to have
almost paralyzed laryngologists, for, with t he exception of my-
self, I hardly know of any one who has ventured a word against
it. Even last year, when I presented a case opposing the the-
ory, and showed a picture of the larynx, it was simply in defer-
ence to myself that not much was said against it. Not a single
member of the Laryngological Association, even of those living
in Philadelphia, where the patient was, would accept my invita-
tion to the members to see the patient for himself, and verify
the fact that the picture I presented was a correct one. The
8
GARLAND: BRONCHIAL BREATHING A SIGN OF PLEURITIC EFFUSION. [N. Y. Mjcd. Jo™.,
only word of commendation I received was from Krause, of
Berlin, who wrote me a very interesting letter, stating that lie
believed my observation was correct, but attributed the lesion
to a different cause. I will recall the case for a moment. A
man had received a wound in the neck. lie had instantly be-
come aphonic, and when I saw him, a few months afterward,
one vocal hand was in extreme abduction. I took it for granted
that the adductor fibers of the pneumogastric had alone been
injured. Krause's explanation is this: The injury of the ca
rotid having been attended with haemorrhage, a clot must have
occurred around the pneumogastric nerve, producing compres
sion, which became permanent by the formation of the oica
trices. I do not know where that patient is now. I have seen
him several times, and the affected vocal band has remained in
extreme abduction.
I have had no experience in such physiological experiments
as Dr. Hooper has made ; but there is a point he spoke of which
receives clinical support. That is with reference to the influ
ence of the facial nerve in sending the respiratory forces to the
pharyngeal. We all know the effect of cold on the facial nerve
in restoring suspended respiration. I remember a casein which
I was called to see a child who had diphtheria following measles.
There was great dyspnoea, but I declined to perform trache-
otomy, because the child was under two years of age, and I
knew that the operation was usually unsuccessful after measles
Knowing the great effect of cold on the facial nerves, in stimu-
lating the facial centers, we placed ice cloths all over the lower
part of the neck and jaw up to the ears. Every time the iced
cloth was placed around the jaw an inspiration took place, and
the physician in attendance, Dr. O'Hara, by his own efforts in
keeping this up, saved the child's life. So many times a minute
he replaced the cloth. Several pieces of cloth were kept be-
tween two pieces of ice. As soon as the piece in position
ceased to produce any effect it was replaced by another. So
there is a point in which, clinically and physiologically, these
facts support each other. The phenomenon of stimulating one
recurrent nerve so that its vocal band passes beyond the me-
dian line in phonation is, if I remember right, confirmatory of
some of Krause's experiments. He states that, when he stimu-
lated one nerve, the vocal band of the opposite side moved also.
It would touch the other, no matter what position it was in,
whether it was in the median line, in the cadaveric position, or
in the inspiratory position. In the case presented by me last
year, when the man tried to speak, the sound vocal band crossed
away over beyond the median line, and beyond the ordinary
position which it occupies in the dead body.
■ Dr. Harrison Allen said that, in his judgment, the analogy
between constriction and adduction, and between dilatation and
abduction, was tenable. At least it was of some value in sug-
gesting research. Careful clinical study would often take the
place of experiments, and it could be certainly shown from the
clinical point of view that adductor muscles and constricting
muscles were alike in their ability to withstand disease as com-
pared to the abductors and dilators. The morphologist could
also assert that the position of a flexed point in a limb resem-
bled the epiglottis when bent down over the aperture of the
glottis, as the extension of the limb- joint might be compared to
the erect position of the epiglottis. In the muscles of the limb
it was found that the adductors were specialized muscles of the
flexor group, and the abductors of the extensor group. Perhaps
it might be well to have distinct terms to express this harmony
of action between flexion and constriction, but, as part of the
study of muscle phenomena taken in a comprehensive sense, the
speaker saw much to show that a close association, if not iden-
tity, existed.
Dr. Ingals. — In support of the paper in a clinical way, I '
have had a recent experience, similar to the one related by Dr.
Cohen, excepting as to the origin. A gentleman had a cold,
over-used the voice during the cold, and in the course of two or
three days became completely aphonic. I saw him five weeks
later, and found complete paralysis of the left cord, which was
fixed in extreme abduction. After two months, there had been
no special change in the position. In phonation the sound cord
did not cross over as in Dr. Cohen's case ; it crossed a little be-
yond the median line, but very little.
Dr. Delavan desired to unite his congratulations with those
of Dr. Cohen upon the paper just presented. It was a most wel-
come and valuable addition to our knowledge of the subject, and
worthy of the highest praise. Reference had been made in the
paper to a motor center for the human larynx. Since he had
first called attention to the existence of such a center several
important contributions had appeared which tended still further
to establish the fact ; he hoped that sufficient clinical and patho-
logical evidence would soon be accumulated to place it beyond a
doubt.
Dr. IIoopek. — I have only attempted in this paper to study
this subject on general physiological and experimental grounds.
Clinically it seems to me a difficult question and one in which
there are many sources of error. We are dealing, in the first
place, with one of the most complicated organs in the body,
and in using the laryngeal mirror we are looking at things
in perspective, which are in almost constant motion. It is
often impossible to say whether a vocal band stands motion-
less in the median line or a few millimetres off from it. If we
call every paralyzed vocal band we see a paralysis of the poste-
rior crico-arytenoid muscle, we can multiply such cases very
rapidly. Not only is the theory that there is a proclivity of
the posterior crico-arytenoid fibers to become diseased contrary
to nature, but the dogmatic manner with which it has by some
been advanced ought of itself to cause us to doubt its accuracy.
I should feel sorry to have an association like our own subscribe
to this notion on the very shallow evidence we have at present.
I must thank you for the attention you have given my paper.
What there is in it which you say has interested you is chiefly
due to the perfect arrangements of the physiological laboratory
of the Harvard Medical School for pursuing such investigations.
The professor of physiology, Dr. Bowditch, and others con-
nected with the department, are always ready with their time
and advice to aid those who are carrying on any kind of re-
search, and I shall, therefore, convey your kind expressions of
interest to the quarter where they really belong.
BRONCHIAL BREATHING A SIGN OF
PLEURITIC EFFUSION.
By G. M. GARLAND, M. D.,
ASSISTANT IN CLINICAL MEDICINE, HARVARD UNIVERSITY.
The differential lines between pneumonia and pleuritic
effusion are ordinarily so clearly and closely drawn that a
mistaken diagnosis between these two diseases would appear
almost evidence of criminal ignorance. And yet such mis-
takes are made frequently and by skillful observers. Cases
present themselves wherein all the physical signs fail of con-
clusiveness, and even the exploratory needle leaves doubt as
to the actual state of affairs behind the chest-wall. I wish
in this article to speak of one group of symptoms which,
above all others, is misleading in pleurisy, and which has,
within my own experience, been productive of mistaken
diagnosis in several instances.
As ordinarily stated in the text-books, the entrance of j
July 4, 1885.] GARLAND: BRONCHIAL BREATHING A SIGN OF PLEURITIC EFFUSION.
9
Diminution
or
Absence of
fluid into the pleural sac obtunds the signs of an air-con-
taining chamber. In proportion as the pleural tide rises the
air-sounds are 'dulled, until the negative list includes:
Respiratory murmur.
Vocal fremitus.
Vocal resonance.
Whispered resonance.
Percussion resonance.
Flexibility of chest-wall.
Silence reigns over the invaded region. This picture is
typical and obtains in the majority of cases. Occasionally,
however, a patient appears with many signs of an effusion,
but, in place of diminished respiratory symptoms, he exhibits
bronchial breathing and whispered bronchophony all over the
dull area. Naturally such symptoms lead one's thoughts
directly to pneumonia, inasmuch as they are declared to be
indicative of pulmonary consolidation, and are even speci-
fied as eliminative of pleural fluid.
Of late years, however, records of such cases have ap-
peared in the journals, and Bacelli, of Rome, not only has
described the symptoms, but has made the occurrence of
whispered pectoriloquy with an effusion in the chest a dif-
ferential point between a serous exudation and empyema.
Now, the question arises how to explain this phenomenon
of bronchial breathing over a fluid effusioD. Bacelli says
that an effusion which is homogeneous in character — i. e.,
serous — will take up and transmit the vibrations of the col-
lapsed lung more readily than a purulent exudation, which
is heterogeneous in character, and hence the occurrence of
audible whispers in the former case and their absence in
the latter. This explanation was eagerly seized by clini-
cians all over the world, and carefully studied until it was
found that it could not be supported by facts. Whispered
pectoriloquy occurs with purulent as well as with serous
effusions, and thus Bacelli's theory falls to the ground.
In my own study of these eccentric symptoms I have
arrived at certain conclusions which I desire to submit to
the judgment of others. In the first place, I have noticed
that bronchial breathing and whispered pectoriloquy have
only occurred with effusions of considerable size. I can not
lay down any boundaries for the amount of fluid necessary
to produce them, and I imagine this amount would vary
with other conditions of the chest-wall and lung. In all the
cases where I have observed these signs, however, the effu-
sion has reached at least to the third rib in front, and in
some instances still higher. Secondly, I can not reconcile
my mind to the theory that the sounds heard are trans,
mitted through the fluid. Water does not readily take up
vibrations from the air. Two stones struck together in the
water cause powerful vibrations of the same, but struck to-
gether above the water, the sound is inaudible to a sub-
merged ear. We know that some heart-murmurs are trans-
mitted long distances. I have traced such murmurs along
the spine from the occiput to the sacrum. Now, when a
murmur is heard in the lumbar region, are we to suppose
that it has taken the short cut through diaphragm, stomach,
pancreas, and bowels to our ear? Sound vibrations, like
electrical waves, travel best along lines of least resistance,
and such lines for the heart-sounds are found along the
ribs and spinal column. The same argument holds good
for the bronchial murmur of pleurisy. As an effusion be-
gins to form, the breath-sounds fade out. They are not
adapted to pass through the water, nor are they strong
enough to overcome other lines of resistance. That bron.
chial breathing is present may be proved by listening to the
lung above the effusion, and especially high up between the
shoulder-blades behind. Two conditions might still bring
these vibrations to our ear when placed over the fluid.
Should the murmur become strong enough to push its way
along the ribs, we should hear it ; or, if the tension of the
chest-wall should be increased in any way so as to convey
their vibrations more readily, we should obtain bronchial
breathing over the fluid. A telephone works satisfactorily
according to the delicacy with which the tension of the
tympanum is adjusted to the vibrations of the impinging
voice. As an effusion of fluid in the pleural cavity in-
creases in size, its weight puts the chest-wall in a state of
increased tension. The intercostal spaces are obliterated —
that is, they are stretched more or less taut. In such a
condition the vibrations which are thrown against the upper
and the back parts of the chest are readily transmitted all
over the surface of the affected side and become audible
over the dull area.
Recognizing this fact, therefore, that bronchial breath-
ing may be conspicuously associated with pleuritic effusion,
we find that this sign is bereft of differential value. Instead
of a light to illumine the diagnosis, it becomes a dangerous
shoal, upon which an opinion may be and often is wrecked.
I need not relate the instances where this bronchial
breathing has, within my experience, led observers astray,
but I will merely refer to one illustrative case : I was called
in consultation to a young lady, twenty-three years of age,
who was thought to have pneumonia in the left side. Upon
examination, I found the signs of a pleuritic effusion, except
the presence of loud bronchial breathing and whispered
pectoriloquy, all over the dull area. These signs were so
marked that they almost shook my interpretation of the
other signs. The impulse of the heart, however, was pal-
pable and visible about one inch beyond the right mammil-
lary line, and the young lady said she had noticed this
beating herself for several days, but had not mentioned it
for fear of being laughed at, if she said her heart was way
over there. I tapped the chest, plunging my needle into the
region of bronchial breathing, and drew off about five pints
of serous fluid. Now, the displacement of the heart was the
key-note to this case, and removed from my mind the
doubts raised by the auscultatory signs. It is, of course,
possible that a congenital transposition of the heart, or its
retention in an abnormal position by adhesions from an old
pleurisy, may render the diagnosis difficult. Such cases
have occurred. Usually, however, the associated trans-
position of other organs or the history of the case will en-
able one to solve the problem. It should be laid down as
a maxim that the determination of the apex impulse should
be obligatory in every examination of the chest, no matter
what the disease or what the nature of the other signs may
be. The man who makes this his habit will often find
occasions to congratulate himself upon escape from error.
10
ELLIOT: HERPES TONSURANS MAGULOSUS.
[N. Y. Med. Joijk.,
HERPES TONSURANS MACULOSUS.
By GEORGE T. ELLIOT, M. D.,
ATTENDING PHYSICIAN TO THE DEMILT DISPENSARY ; ASSISTANT VISITING
PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL, ETC.
The name herpes tonsurans maculosus is given to an
acute eruption disseminated more or less over the entire
body, and caused by the vegetable parasite, the Trichophyton
tonsurans. It is comparatively infrequent in its occurrence
here, and, though it has a common origin with ordinary
ringworm, yet it differs from this in the manner of its in-
vasion, the acuteness of its development, the extent of sur-
face implicated, and in its general course. The individual
lesions retain, however, the salient characteristics of the
ordinary form.
The conditions under which it may occur are the same
as those favoring the development of ordinary ringworm —
viz., damp lodgings, clothes, etc. ; immediate infection, etc.
Its own power of infection, in the earlier stages at least,
does not seem, however, to be very active, and, in the many
cases which I have observed, I have not yet been able to
trace its having been communicated from one person to
another, though all conditions for such communication were
present. In fact, one of the patients whose cases are re-
ported here, was for nearly two weeks in constant contact
with another lady before the disease was treated, and still
no infection occurred. The other patient, a boy, slept with
his mother during the entire time that the disease was
present, and yet she remained free from it.
In all probability an outbreak of herpes tonsurans macu-
losus is due to multiple infection. The spores of the para-
site, obtaining access to the skin at many points, develop
rapidly under suitable conditions. The simultaneous out-
break of many lesions, it may be on one part of the body,
as an upper or lower extremity, or on various parts widely
separated from each other, and many other factors, speak
for this manner of origin. These primary lesions may,
however, again serve as foci of infection, inasmuch as the
scales of epidermis, being detached by the movements of
the body, the friction of the patient's linen, carry the spores
to other as yet unaffected portions, where the process be-
gins anew. A succession of outbreaks thus appears until, in
a short time, the patient is covered with the lesions in all
stages of development.
There is no particular localization to the disease, and
no portion of the body is invulnerable to its attack. The
backs and flanks are, however, usually more thickly studded
with the lesions, but they are also found in great numbers
on the face, neck, chest, abdomen, and extremities. The
outbreak of the affection may be preceded by malaise, some
fever, loss of appetite, and symptoms of general disturb-
ance. In the course of the disease the irritation and con-
sequent loss of sleep in children may give rise to serious
anxiety.
The eruption first appears upon the portion of the body
affected in the form of small papules about as large as a
millet-seed, of a pale-red color, which disappear on pressure,
and are slightly elevated. On those parts where there is
much perspiration the color of the lesions is a dark red.
Shortly after the appearance of the papules — it may be
only a few hours — peripheral growth lias ensued and slight
exfoliation of the epidermis will be observed in the centers,
while the edges remain smooth and red. The lesions are
at first circular, but, as they grow larger, many become oval
in shape, their long axes lying in the direction of the cleav-
age lines of the skin. Their development is at first rapid,
and in the course of a week or ten days they attain the size
of a twenty-five-cent piece, or even larger. Where the edges
of two or more of the lesions come together, the portions
which were in contact disappear and a gyrate form of erup-
tion remains. As the lesions increase in size their edges
become more elevated, are of a bright red, and scaly, fading
gradually away into the surrounding tissue. At times vesi-
culation is observed. The central portions are more or less
scaly and in process of involution, but in the larger lesions
these squamas have ceased forming and the skin may be
found perfectly normal. As they become older they acquire
a dirty, light-brown color, and they approach more nearly to
a typical ringworm. Many of the lesions, however, do not
follow this course, but abort and disappear a few days after
their first appearance. The itching of the eruption is not
very severe, unless, through improper treatment or from other
causes, a consecutive eczema or dermatitis complicates it.
If left to itself, the disease runs its course in from two
to six months. The edges flatten out, the erythematous
condition disappears, desquamation occurs, and the skin be-
comes again normal. Slight pigmentation may remain for
a variable length of time. One spot often remains, especi-
ally on those parts of the body which are well protected,
and may serve as a focus for reinfection. If the epidermis
scales are examined under the microscope, the mycelia and
conidia of the Trichophyton tonsurans will be found, but
very sparingly, in the younger lesions. In ordinary ring-
worm, any small epidermis scale will show large numbers of
the parasite, but a search for hours through squamae taken
from young spots of herpes tonsurans maculosus will be
rewarded by the discovery of only a few spores, and perhaps
a beginning mycelial formation. As the lesions, however,
become larger and approach more nearly the type of ordi-
nary ringworm, the presence of the parasite is easily de-
monstrable.
The diagnosis presents no special difficulty to the der-
matologist, and should not to the practitioner in general, if
the determining characteristics of ordinary ringworm are
kept in mind. Only at its first appearance can it be mis-
taken, but its development is so rapid that ordinary observa-
tion very soon clears up any existing doubt as to the nature
of the eruption. Should an eczema complicate the disease,
the finding of a fresh and uninjured lesion will demonstrate
the real disease present.
The histories of the two cases which I desire to report
are as follows :
Case I. — Miss states that the eruption from which she
suffers has existed for two weeks, and that during that time she
has received no treatment. Two days before I first saw her, on
December 20th, she consulted Dr. Robert Abbe, who kindly re-
ferred her to me. She informed me that about six months before
she had had on the outer surface of the left thigh a circular spot
July 4, 1885.] BARUCH: THERAPEUTIC SIGNIFICANCE OF TEE CERVICAL FOLLICLES.
11
with red elevated edges, the center of which was covered with
squamae. It itched slightly, but caused no special trouble, and
finally disappeared, though it received no treatment. The erup-
tion with which she was afflicted at the time I saw her was
preceded by some feeling of malaise and general disturbance,
and showed itself simultaneously on neck, flanks, and thighs,
under the form of small, erythematous, slightly itchy papules.
They were rather closely aggregated, and peripheral enlarge-
ment took place rapidly. At first she paid little attention to
the eruption, until the continued appearance of fresh lesions
and the growth of the primary ones suggested to her the advisa-
bility of consulting a physician. On examination, the following
condition was found : On the face and neck, and along the margin
of the hair, on the shoulders, arms, and backs of the hands, the
entire trunk, the thighs as far as the knees, and on the left heel,
there was an eruption of papules, circular, oval, and gyrate spots
of all sizes and in all stages of development. In the axillae and on
the mons Veneris were likewise a few lesions. All the charac-
terizing objective symptoms were present, and there was no hesi-
tation in deciding upon the nature of the affection. The largest
lesions, situated on the left thigh near the crest of the ilium and
on the back, were of the size of a twenty-five-cent piece, and
oval in shape. The itching was not very severe, but still enough
to cause some discomfort. Some of the scales from the younger
lesions were examined under the microscope, but beyond a few
spores nothing was found. An anti- parasitic treatment was im-
mediately instituted, consisting of salicylic acid dissolved in
alcohol. Two days later, December 22d, the patient reported
slight improvement, but many new lesions had appeared on the
abdomen, mammae, etc. Those on the back and thighs were
improved.
December 2I^th. — Improvement was more marked. No new
spots had appeared, and a decided change could be seen in those
already present. Some had completely disappeared, while even
in the larger ones the prominence of the edges and the ery-
thematous condition had greatly decreased. Treatment was
continued.
30th. — The disease was substantially cured. No new lesions
had appeared since her last visit, the erythematous condition and
elevation of the edges had disappeared, and there remained only
here and there some roughness of the skin, though in many places
where the disease had been present the skin was already nor-
mal in appearance. Treatment was suspended and an indiffer-
ent ointment was ordered, to relieve the slight irritation which
the lotion had produced.
The patient returned, however, ten days later. There had
been an outbreak on the inner surface of the thighs, and perhaps
a dozen new spots had appeared. A few days of the treatment
brought these to an end, and there has been no new return of
the disease.
Case II. — In May, 1884, while I was attending the dermato-
logical class at the Bellevue Out door Department with Dr. W.
G. Robinson, a boy of twelve presented himself for treatment,
complaining of an itchy eruption situated principally on the
trunk, and to a lesser degree on the extremities and neck, which
had first appeared one week previously. Any description as to
its first appearance, or his condition at the time, could not be
obtained.
On removing his clothes, an extensive eruption was found
covering the portions of the body already mentioned, and consist-
ing of lesions of about the size of a five-cent piece. They were
rather uniform in size, and to a large extent were undoubtedly
of the same age. They presented the characteristic objective
appearances already mentioned as marking an outbreak of
herpes tonsurans maculosus. They were all of a light-brown
color, and little erythema was present, but this was evidently
due to his decided aversion to the laws of cleanliness. Anti-
parasitic treatment was immediately instituted.
The patient returned in four days, and it was found that the
spots had not increased in size, that no new ones had appeared,
and that the itching had diminished to a great extent. He was
directed to continue treatment and to return in a week. On
presenting himself after that time all signs of the disease were
gone. There was only a slight roughness of the skin remaining.
As may be seen, these two cases presented substantially
the same appearances and course. In both the disease was
comparatively recent, and, though existing in the vicinity
and on parts covered with hair, had not been communicated
to the hair follicles and hairs. If this had occurred, the cure
of the eruption would necessarily have required a greater
length of time and more special treatment.
The treatment of this form of disease caused by the
Trichophyton tonsurans is in substance the same as that used
in the other forms, only some care should be taken in the
choice of the anti-parasitic. It should be borne in mind
that an application limited to the lesions alone or to a cer-
tain number of them at one time will be useless; it is abso-
lutely necessary to apply the anti-parasitic remedy to the
whole body, even upon those portions which appear perfectly
normal. It is important to check the progress of the disease
as quickly as possible, and, the longer it is temporized with,
the greater the difficulty in curing it, and the greater the
risk that an eczema or a dermatitis may arise to complicate
it. After the arrest of the affection, and there is a certainty
of the death of the parasitic spores, the skin should be pro-
tected by the inunction of some bland salve, and powder
should be freely used. More or less exfoliation of the epi-
dermis occurs, and the skin becomes normal in from a week
to ten days.
23 East Thirty-first Street.
THE THERAPEUTIC SIGNIFICANCE OF
THE CERVICAL FOLLICLES.
By SIMON BARUCH, M. D.,
GYNECOLOGIST TO THE NORTHEASTERN DISPENSARY, NEW YORK.
(Concluded from page 720.)
The subject of uterine catarrh is referred to incidentally
and not with a view to discuss it here, because I desire to
point out the different conditions of the glands in disease
of the cervix. In the latter atrophy is the exception, cystic
degeneration being followed by it only after a very long ex-
istence of the process. A different method is indicated in
cervical catarrh ; the glandular structure must be reached
by the treatment if we would succeed. The cyst-like dis-
tension must be removed by laying open the walls of the
glands. The latter being very numerous, and their walls
somewhat tough and resisting, the application of remedies
should be preceded by scarification of the mucous mem-
brane and submucous glandular structure, and in the more
obstinate cases, where no cellulitis coexists, the sharp curette
would answer a good purpose. Whether the catarrh be
corporeal or cervical, therefore, the glandular structure is
the secreting structure, and it must be reached by the
means indicated. The patient is carefully prepared by re-
ducing any pre-existing cellulitis, and softening infiltration
12
BARUCH: THERAPEUTIC SIGNIFICANCE OF TEE CERVICAL FOLLICLES. [N. Y. Mkd. Jo™.,
in the annexa by the usual remedies, rest, hot douches, gly-
cerin tampons, etc. If the disease is extensive, or the pa-
tient very nervous, an anaesthetic may be required. While
the patient lies in Sims's position, the cervix and vagina are
thoroughly irrigated by an antiseptic solution ; a Wilson's or
Goodell's dilator, previously rendered aseptic, is introduced
into the cervical canal for the purpose of dilating it to the
required caliber. A blunt- pointed bistoury is now made to
scarify the canal longitudinally and somewhat deeply. If a
sharp curette be now made to scrape over the surface, it
will bring away more or less glutinous, glairy fluid from the
ruptured cystic follicles, and perhaps some debris of the lat-
ter. A thorough swabbing with tincture of iodine, after
bleeding has been somewhat checked by pressure, completes
the operation. A carbolized glycerin tampon of cotton or
oakum will neutralize the discharge and allay irritation.
Hot antiseptic douches may afterward be resorted to daily
and the treatment continued on ordinary principles. By
adopting the course here mapped out, we follow the teach-
ings of modern surgery, which are applicable in gynecology
as well. The method here proposed may appear somewhat
heroic, but we have a heroic disease to deal with. More-
over, it is well known that even more radical measures have
been advocated and practiced for the cure of obstinate cer-
vical catarrh. Schroeder has recommended very highly, for
the cure of those obstinate cases in which great glandular
enlargement of the mucous lining exists, the excision of the
entire diseased mucosa. He makes a.n incision on each side
of the cervix, so as to divide it into two separate halves, up
to the inner os. The mucous membrane and glands are
dow removed by an incision passing through the cervical
parenchyma ; each lip is turned upon itself, and its folded
surfaces are stitched together, so that the entire cervix is
covered within and without by squamous epithelium. Ols-
hausen reports eighty cases, and he regards this operation,
done under continuous antiseptic irrigation, as not only free
from danger, but remarkable in its results. Hegar, Kehrer,
and others have devised similar operations. All these sur-
gical procedures prove the great significance of the cervical
follicles, for it is evident that the removal of the mucosa
containing them is regarded as the most essential element
in the treatment of intractable cases of uterine catarrh.
The radical cure of so-called hypertrophy of the uterus,
chronic metritis in the various forms in which the cervix is
involved and involution has been interrupted, has frequently
been accomplished hy A. Martin (" Arch, fur Gynaekolo-
gie," 1879, 488). The failure of all local therapeutics by
caustics, injections, etc., has placed this malady in the
category of incurable diseases. Carl Braun had shown in
1864 that involution was hastened by amputation of the
cervix, and Martin followed and confirmed Braun's ideas.
He operated in seventy-two cases, chiefly complicated with
ectropium, erosions, and ulcers of the portio vaginalis,
with perfect cure in sixty-four cases; portions 3 to 4 ctm.
long were removed, and in the course of a few weeks com-
plete involution resulted. Kehrer and Schroeder, also He-
gar, cited similar experiences during the discussion, the
former citing forty to fifty cases in which he obtained good
results by excision of triangular pieces on each side and
union of the edges (is this not akin to Emmet's opera-
tion ?).
In this country these heroic operations have not received
much approbation, first, because they mutilate and dis-
figure the cervix uteri more or less, or, when the latter is
entirely removed, it becomes difficult to retain the uterus
in position ; and, second, because we have in Emmet's opera-
tion a superior procedure in the class of cases referred to by
Schroeder and Martin, which, occurring in parous women,
are almost invariably connected with lacerations of the cer-
vix. There had been no operation devised which removed
diseased tissues and at the same time restored the cervix to
an almost normal form and condition after the traumatism
of childbirth before Dr. Emmet gave to the world his now
classical operation of trachelorrhaphy. Indeed, to him we
owe the recognition of the fact that a lacerated cervix com-
pletely or partially healed, combined with more or less
cellulitis, is at the bottom of the great preponderance of
uterine diseases, outside of neoplasms and malpositions.
But what Dr. Emmet has taught, and is still teaching with
more emphasis than all else, and what yet is more neglected
and misunderstood, is the principle that his operation is not
intended as a plastic procedure for the reunion of the torn
edges of the cervix, but that its aim and scope lie far beyond
the mere aesthetic effect, in the removal of diseased tissues, to
ivhose presence are due the local and especially the reflex
symptoms which we are called upon to treat. It is remark-
able how slowly the appreciation of this principle and of
these facts, which we daily observe here, has dawned upon
gyna?cologists abroad. It is not so surprising that lacera-
tions of the cervix were not recognized in England so long
as they were sought for through the old tubular speculum,
because only their exposure by Sims's speculum, and the
approximation of the torn edges by means of tenacula,
could convince skeptics. In Germany, however, where
Sims's and Simon's retractors are in constant use, Emmet's
views have not received that warm appreciation which is
accorded to them in this country. The reason is obvious to
any one who is familiar with German gynaecological litera-
ture, which contains the most garbled descriptions and
most erroneous views concerning the operation for lacer-
ated cervix. For instance, Olshauseu says ("Klinische Bei-
trage zur Gynaek. und Geburtskulfe," 1884, p. 32), in re-
ferring to Schroeder's operation : " We agree with him
that, in the so-called laceration-ectropium, it is more safe,
and at the same time a not more serious procedure, to ex-
tirpate the diseased mucosa than to make the Emmet
' ectropium operation.' We have, therefore, not been able
to become friendly to the latter, and have only executed it
a few times." Dr. Emmet's operation is really intended to
" extirpate the diseased mucosa." Hegar tells us (" Hegar
und Kaltenbach," 1881, p. 539) : "Emmet hopes, by simple
union of sutures, to relieve the patients of all their troubles
and to produce a recession of the tissue changes " ; and He-
gar dismisses the description of the operation for lacerated
cervix in these words : " While the assistant holds the lips of
the os uteri on a stretch, the edges of the tear are freshened
smoothly and thoroughly by knife or scissors ; the fresh-
ened surfaces are brought together by needles, etc. As the
July 4, 1885.] BARUCH: THERAPEUTIC SIGNIFICANCE OF THK CERVICAL POLLICLES.
operation is only slightly painful, chloroform is usually dis-
pensed with " •(!).
These brief references from prominent German authors
afford ample evidence of the fact that the principle as well
as the technique of Emmet's operation ia not understood.
Any one who has seen Dr. Emmet operate will smile when
he reads the description given by Hegar. AVhoever has
seen Dr. Emmet labor from ten minutes to an hour, or even
longer, over a lacerated cervix, digging and snipping away
diseased glands and cicatricial tissue, knows that it is not
the slight operation described by Hegar, and will appreciate
how egregiously his work is misrepresented abroad. We
can not wonder that the imperfect knowledge of this valu-
able surgical procedure has failed to establish its useful-
ness. Only a few days ago I heard Dr. Emmet inveigh
bitterly against the practice of superficial denudation. He
said that he believed the operation was doing more harm
than good, because every novice deemed himself competent
to perforin it without really understanding the essential prin-
ciple, which was " to remove the cicatricial plug.'1'' He also
said that he never operated for lacerated cervix unless there
were symptoms indicating the necessity for the procedure.
While I appreciate fully the fact that the mere existence
of the laceration of the cervix is not the exciting cause of
those symptoms which keep the poor woman in a constant
state of invalidism, I do not believe that the latter are in-
variably, or even frequently, due to "a cicatricial plug,"
but that at least the catarrh and the erosion, and probably
also the reflex symptoms, owe their origin to Another factor,
viz., disease of the glandular structure, which is almost in-
variably present. In those trying cases of cervical catarrh
connected with abrasions, hyperplasia of the cervix, and
subinvolution, which are the fertile source of ill-health in
parous women, and to detail whose symptoms would be to
you but an oft-told tale, a lacerated cervix is, as I have said,
a frequently co-existing condition, and constitutes, together
with more or less pelvic cellulitis, the chief element in the
case. That this is a clinical fact is attested by the results of
the operation of trachelorrhaphy when properly executed,
viz., when it is done not alone f jr the purpose of restoring
the tear, but for the 'purpose of extirpating the diseased
mucosa, with its numerous diseased follicles, down to the
healthy parenchyma.
I show you here a specimen of this condition, and
you will see one of the glands forming a large cyst, which
I have opened for your inspection. All the pathological
changes which have been detailed under the general head
of cervical catarrh, as involving the mucous membrane,
are here seen in an exaggerated form, owing to the ob-
struction in the circulation of the cervix, the eversion of
the lips, and the neighboring cellulitis. Erosions, too,
present an additional source of pain and discharge. No
application of caustics will cure these cases, for how can
we penetrate these callous structures and cyst-walls ? We
may heal the erosions over by a slow process, squamous
epithelium taking the place of the cylindrical or the everted
mucous membrane. We may by this means check the
secretions from the surfaces within reach of applications,
among which nitrate of silver has proved the best, but
Uj
yet the most harmful eventually, because of the inodular
tissue produced by it. Crude pyroligneous acid is much
used by the Germans in erosions. But so long as cystic
degeneration of the follicles remains, so long as new cysts
form, our patient will continue to suffer the backaches and
reflex symptoms which render her life miserable. How
often women apply for relief under these conditions, and
how rarely they receive it by medicinal application, is within
the experience of all. But, if we have regard for the true
cause of these symptoms, we may afford them relief by simply
puncturing the glands separately, or, what is better, by deeply
scarifying the entire everted surface, from the inner os to the
point beyond'the junction of the vaginal covering of the cer-
vix, by radiating incisions. The haemorrhage may be a little
free, but can readily be checked by pressure. The relief from
distress is marvelous ; and those who have seen these poor
women return again and again with the request for the same
treatment will not be skeptical regarding my proposition,
that in these diseased and distended glands lies the true cause
of the trouble. Indeed, such cases may, by scarification, hot
douches, glycerin tampons, and rest, be almost entirely
restored, unless the latter important element can not be
gained, as is the case in women who have household or
other duties to perform. In the latter, as also in the more
pronounced and intractable forms among the better circum-
stanced, nothing short of trachelorrhaphy will bring perma-
nent relief. But the operation should be thorough ; all dis-
eased and hyperplastic structure should be removed, and
the cervix should be restored as nearly as possible to its
normal size and shape. Unfortunately, there are specialists
even who do not in this respect follow the principles laid
down by Dr. Emmet, and who, as he says, inclose the "cica-
tricial plug," whose removal he regards as paramount, in
the newly made wound. Among gynaecologists in this city
even I have seen few who succeed in giving the cervix
after this operation an almost virginal shape, as Dr. Em-
met almost invariably does, by first slitting up the angle
for the removal of cicatricial tissue, and then bringing
the edges together by deep sutures directed toward the
angle of the wound and not across from one edge to the
other. I am disposed to believe that it is not this re-
moval of the "cicatricial plug " which renders Dr. Emmet's
operation in his own hands so signally successful, but that
the solution lies in the complete ablation of the diseased
gland structure which necessarily follows the removal of
this cicatricial plug. When a considerable wedge is excised
from the angles of the laceration, the surgeon is compelled
to resort to free ablation of the thickened flaps, in order to
bring them into nice apposition, if he would avoid inclosing
a deep gap in the angle ; the result is a cervix almost vir-
ginal in appearance, which I have seen very few surgeons
besides Dr. Emmet able to produce. Let it be borne in
mind that the great aim of the operation of lacerated cer-
vix is the removal of the diseased gland structure ; let this
be unsparingly removed, and this great health-saving and, I
believe, life-saving operation will perform its proper func-
tion.
There is no treatment for subinvolution which can com-
pare to trachelorrhaphy in brilliancy of results. When we
14 BARUCH: THERAPEUTIC SIGNIFICANCE
read the description of this disease, which is now known to
be almost invariably only a portion of a complexus of con-
ditions following an imperfect "getting up " from childbed ;
and if we compare the results of treatment by ergot, tonics,
baths, astringents, electricity, and injections, which was in
vogue several years ago, with the brilliant results of trache-
lorrhaphy— we find cause to congratulate ourselves on the
fact that we live in this happy era in which surgery counts
its triumphs daily.
A few weeks after the wound is healed the uterine canal
shows a decrease of depth, there is new life infused into its
circulation, involution is re-established, and with it the pa-
tient is restored to health. How many weary years have
been passed in bootless medication, how many days and
months of invalidism have been suffered ere this happy
consummation was reached by one brilliant stroke of the
surgeon's hand, the sufferer often tells with a sorrowing yet
with a grateful heart.
Some twelve years ago I wrote an elaborate article on sub-
involution for the Charleston, S. C, " Medical Journal," in
which I presented all the remedies which were at that time
thought efficient. The recollection of my lengthy account
of the therapeutics of this affection has led me to these re-
flections upon the comparative advantages of the present
method of treating subinvolution.
In those cases of cervical disease termed ulceration and
erosion the follicles are again found to enact an important
pathological role. Whether they become more freely de-
veloped on their original site, as maintained by Fischel, or
whether a new formation of follicles ensues, as is, with more
convincing proof, asserted by C. Ruge, the fact is established
beyond contradiction that so-called erosions of the portio
vaginalis rest upon a groundwork of glands. " The entire
eroded spot," says Ruge, "is the free surface of a new de-
velopment of glandular structure! upon the normally gland-
less portio vaginalis; it is covered with a cylindrical epithe-
lium in single layer. At the same time are formed numer-
ous depressions into the tissue, which in single spots are
still solid, but soon become hollow, and present themselves
as glandular tubes or bags, which, penetrating deeply
into the tissue, branch freely and communicate often with
neighboring glands. From the latter arise partly con-
stricted rounded formations whose inner walls are covered
with very fine papillary projections. Repeatedly we found
a complete spongy system of glands. The larger glands lie
in the mucosa, but even muscular fibers do not hinder their
further development. In many cases they reach such mas-
sive accumulation that all normal structure is pressed aside.
All these constrictions and depressions have cylindrical epi-
thelium which resembles the more superficial. The inter-
vening structure is a young connective tissue permeated by
numerous capillary loops. In a peculiar manner we found
repeatedly real gland lamina as well as follicle-like forma-
tions on parts where the portio vaginalis was covered super-
ficially by normal epithelium and where the papilla? even
showed no change. Their origin is very probably due to the
small crypts which in the cervical canal are covered with cylin-
drical epithelium [italics mine], but which are sparse in the
portio, by means of the deep penetration of these crypts in a
OF THE CERVICAL FOLLICLES. fN. Y. Med. Jodb.,
direction from within outward toward the portio, whose epi-
thelium they push before them. It is possible that they may
partly arise in the connective tissue of the portio vaginalis."
From this description of the pathology of erosions it would
appear that the follicular structures form their basis, and that
it would be irrational to attempt to cure these surface
breaches without destruction of the gland-tissue. Strong
acids answer a good purpose here, because the diseased sur-
face is within easy reach and may be again and again sub-
jected to treatment.
But the more radical removal by the sharp curette or
spoon, or by scissors and knife, as is best done by Emmet's
or Schroeder's operation, leads to a more rapid and successful
issue, and affords a permanent result, because the glands,
which are the chief pathological factors, are thoroughly re-
moved. I have no experience with Schroeder's operation,
but Emmet's trachelorrhaphy, or some modification of it,
has served an excellent purpose in such cases.
The radical extirpation of the gland-tissue becomes more
imperative if we accept the view of Huge and Veit, that there
is not only a close relationship between erosions and cancer,
but that many cases of cancer may actually be traced to an
origin in the gland structure. The process of repair in these
erosions confirms this view.
" While in the repair of erosions, in some cases, the
cylindrical epithelium transforms itself into squamous epi-
thelium, which, by increase and layering, gradually narrows
the gland-outlets more and more, compresses them, as it
were cuts them off, so that they persist under the squamous
epithelium ; on the other hand, instead of this incomplete
healing, the squamous epithelium may creep into the glands.
Often the upper half of the gland is found already filled.
But another process of termination may occur. Frequently
everything up to a small piece of gland-tissue, correspond-
ing to its bottom, may be converted into squamous epithe-
lium or into a better-layered, polymorphous, dermoidal epi-
thelium. In short, we obtain in these processes of cure
pictures such as we have frequently described in the devel-
opment of cancer, as beginning of the latter. A gland in
process of cancerous degeneration is not to be distinguished
from one in process of cure. In the cervix an analogous
process of cure takes place when an erosion becomes covered
by epidermis ; the squamous epithelium which forms in sim-
ple ectropium, or in prolapsus with ectropium, often creeps
into the gland only on one side in order to fill it gradually n
("Zeitschr. fiir Geburtsh. und Gynaek.," 1881, p. 174). The
pathological study of cervical diseases which are here pre-
sented briefly points to the inevitable conclusion that the
cervical follicles are significant factors in all benign diseases
of the cervix uteri.
The connection between benign and malignant disease
of the cervix has already been referred to. It remains now
to show more definitely how far the cervical follicles are sig-
nificant as elements in the pathology of that most loathsome
of all titer ine diseases, carcinoma. I must again draw from
that valuable source of information on pathology, the labors-
of Ruge and Veit, who have examined numerous specimens
of carcinomatous tissue, removed, in various stages, by Carl
Schroeder and others. The minute descriptions of the mi-
July 4, 1885.J BARUCH: THERAPEUTIC SIGNIFICANCE OF THE CERVICAL FOLLICLES.
15
croscopic appearances, which are beautifully illustrated in
their work ("Der Krebs der Gebarmutter," "Zeitsch. fur
Geburtshiilfe unci Gyna3kol," 1881), establish beyond a doubt
the correctness of their view that carcinoma of the cervix origi-
nates in the follicles. " When it develops within the cer-
vix, it arises from the connective tissue or the already pres-
ent though rankly growing glands, while, when it develops
on the portio vaginalis, it takes its origin in the connective
tissue or in newly formed glands. Hence both forms have
this much in common, although they differ in some other
respects : that a glandular formation serves them as their
point of origin " (pp. 208, 209).
It would probably interest you as deeply as it interested
me during the investigation of this momentous question to
follow these practical microscopists, who are intimately con-
nected in their work with Berlin's best clinical gynaecolo-
gists, in the description of some of the microscopic draw-
ings which they furnish. But I will quote very briefly, in
order to impress upon your minds the salient points in con-
nection with my subject, only the concluding summary (p.
169) : " First, the squamous epithelium was found sometimes
slightly thickened near the end (of the portio) ; next fol-
lowed glandular erosions, covered with cylindrical epithe-
lium which degenerated into cancer. In many cases in
which cancer apparently occurred upon the plain termina-
tions of the squamous epithelium, its development from
glands could frequently be demonstrated beyond a doubt.
We can say that a large proportion of carcinoma of the
portio vaginalis are gland cancers, which receive their origin
in newly developed glands (erosions). We therefore still
remain upon our former standpoint, that erosions are not
always simple and insignificant processes. We are glad (in
reply to Scanzoni, who said that the incipient stages of de-
velopment of cancer were unknown) to say that we have seen
early development of cancer, and that we have demonstrated
for this category a development from glands."
What lessons are inculcated by the pathological evi-
dences which I have brought before you to prove the para-
mount influence of the gland structure as a factor in benign
as well as in malignant diseases of the cervix uteri ? The
original intention of my studies on the subject was to
demonstrate the urgent necessity of recognizing the gland
structure in the operation for lacerated cervix, to show how
important the mere repair of the laceration would be in the
direction of a cure, and to insist upon the necessity of free
thorough, and unsparing removal of all gland-tissue in this
operation. But, as the subject became more and more
elaborated in my mind, I was led into the more complete
review which is here presented.
Ruge and Veit have told us : " A gland in process of
cancerous degeneration is not to be distinguished from one in
process of cure.'" Pregnant words these from the pen of
careful observers, reminding us how readily the scale may
be turned from a benign to a malignant process.
The microscope has confirmed the conclusions which
clinical observation has furnished. Dr. Emmet has long
insisted that epithelioma of the cervix was almost invari-
ably connected with a previously existing laceration, having
never discovered epithelioma in women who had not at
some time been delivered of a fcetus. Breisky, Gusserow,
Hofmaier, and others have confirmed Emmet's view to this
extent at least, that, in their experience, carcinoma of the
cervix is comparatively rare in nullipar.ius women.
The lesson, therefore, is plain. Lacerations, erosions,
and ulcerations, which do not readily respond to ordinary
treatment, must be regarded with suspicion as possible
sources for the development of malignant disease. When
surgical measures are demanded for their repair, the removal
of the gland structure is paramount, and should be executed,
as vigorously as is done in true malignant disease, by en-
croaching as far as possible upon the healthy parenchyma
of the cervix. . This complete extirpation of the gland
structure will not only secure a complete cure in benign
cases, but prevent the possible development of malignant
disease.
Summary.
1. A thorough knowledge of the anatomy, physiology,
and pathology of the cervical follicles will simplify the
treatment of many uterine affections.
2. The cervix uteri represents a large gland of active and
important function in the various sexual relations of woman.
3. In the majority of the more common diseases of the
uterus the mucous membrane and its follicles play the most
important role. A recognition of this fact will make treat-
ment more successful.
4. Metritis, subinvolution, hyperplasia with catarrh, ero-
sions, etc., must be studied in connection with the glands
of the cervix.
5. In obstinate cases medicinal applications fail because
the secreting surfaces of the follicles are not reached.
Scarification and the curette are valuable adjuncts in nulli-
parous women or in parous women without cervix lacera-
tion.
6. In parous women with lacerations, trachelorrhaphy is
the most valuable procedure. As a simple plastic operation
it will fail. Success depends on extirpation of the follicles,
which is more important than " removal of the cicatricial
plug."
7. The microscope demonstrates the dependence of ca-
tarrh, ulceration, erosion, and hypertrophy of the cervix, and
often also of the body of the uterus, upon the glandular
structure of the cervix uteri.
8. The cervical follicles are significant as elements in
the pathology of cervix cancer, because the microscope
demonstrates the dependence of the latter upon erosions,
which are based upon the gland structure.
9. Laceration and erosion must be regarded with sus-
picion, as possible sources of future malignant disease. In
operating for their removal, extirpation of the cervical folli-
cles must be unsparing.
Protective Choleraic Inoculation in Spain, under the direction of
Dr. Ferran, the Government prohibition of which has been withdraws,
is to be further prosecuted, as we learn by the " Union medicate, " un-
der the observation of a French commission consisting of Professor
Brouardel, M. Roux, who is an assistant of Pasteur's, and M. Albarran,
the last-named gentleman having been chosen on account of his knowl-
edge of the Spanish language.
The Honorary Degree of LL. D. has been conferred on Dr. Thomas
F. Rochester, of Buffalo.
16
BOOK NOTICES.
[N. Y. Use. Joi k.,
^ooh flotites.
Lectures on Diseases of the Nervous Sytsem, especially in Women.
By S. Weir Mitchell, M. D., Member of the National Acad-
emy of Sciencs, Physician to the Orthopaedic Hospital and
Infirmary for Diseases of the Nervous System, etc. Second
Edition, revised and enlarged, with Five Plates. Philadel-
phia : Lea Brothers & Co., 1885. Pp. 287. [Price, $1.75.]
Dr. Mitchell's numerous admirers will welcome a new edi-
tion of hi? interesting little volume, especially as it contains
several fresh pages on the subject of hysteria, on which he
always writes so graphically. Chapter XVI, on "The Rectum
and Defecation in Hysteria," contains a number of curious and
interesting facts concerning this protean disorder. The closing
chapter contains a concise statement of the advantages and
method of application of the rest-cure, which the talented au-
thor has already rendered so famous.
The subject of chorea is carefully treated of, the relation of
the disease to locality and meteorological conditions heing care-
fully studied and illustrated by charts. The style is, like that
of all of the author's writings, clear and forcible. Aside from
its scientific value, the book offers most interesting reading.
Modern Therapeutics of the Diseases of Children, with Observa-
tions on the Hygiene of Infancy. By Joseph F. Edwards,
M. D., Editor of the "Annals of Hygiene," etc. Philadel-
phia: D. G-. Brinton, 1885. Pp. vii-17 to 346, inclusive.
The author modestly remarks in the preface that "no simi-
lar work of anything like this extent has ever been published,"
a statement calculated to raise the expectations of the reader to
a high pitch. Unfortunately, these expectations are not en-
tirely realized. The volume certainly contains a number of
valuable suggestions, and will be acceptable to a certain class of
readers, but, to tell the truth, there is so much waste matter in
it that the true pearls are hard to find. Numbers of the pre-
scriptions which are credited to certain modern physicians have
been in use for over a century, and many of the " eminent spe-
cialists " whose teachings are quoted are unknown to fame.
The main criticism to be urged against the book is its pro-
lixity. The writer has certainly devoted an immense amount
of time to the compilation.
The Year-Boole of Treatment for 1881f. A Critical Review for
Practitioners of Medicine and Surgery. Philadelphia : Lea
Brothers & Co., 1885. Pp. 316.
This little volume contains a large amount of useful infor-
mation within a small space. The names of the contributors
are a sufficient guarantee of the accuracy of the work. The
paragraphs, although necessarily condensed, are sufficiently full ;
the references to current literature are carefully given, and
show wide research. Although the writers are English, they
generously allow a fair amount of space to extracts from Ameri-
can journals. We note, as especially worthy of commendation,
the sections on " Diseases of the Stomach, Intestines, and Liver,"
by Dr. Brunton ; on "General Surgery," by Mr. Bryant; and
on "Diseases of Women," by Dr. Williams. Mr. Champneys
contributes a lengthy chapter on "Midwifery," and Mr. Mal-
colm Morris an excellent resume of the latest advances in the
department of dermatology. There are two carefully prepared
indexes, one referring to the authors quoted, the other to dis-
eases. The book is of a size suitable for the pocket, and the
type and binding leave nothing to be desired.
Modern Medical Therapeutics: A Compendium of Recent For-
mulas and Specific Therapeutical Directions, from the Prac-
tice of Eminent Contemporary Physicians, American and
Foreign. By George H. Napheys, A. M., M. D., etc.
Edited by Joseph F. Edwards, M. D., and D. G. Brinton,
M. D. Eighth Edition, Enlarged and Revised. Philadel-
phia: D. G. Brinton, 1885. Pp. xv-629.
The fact that this work has reached an eighth edition proves
that it must be popular with the profession, yet this is not
necessarily an argument in favor of its intrinsic excellence.
Although we do not regard with much favor the regular prac-
tice of borrowing other men's prescriptions, there are undoubt-
edly useful hints to be derived from a study of the methods of
treatment employed by different practitioners. The advantage
complacently set forth by the editors, that the present edition
has been increased by "more than a hundred pages," will not
strike the thoughtful reader as especially great. There is too
much irrelevant matter in the book already. The size of the
volume is the least of its attractions. While, as we before re-
marked, we do not become enthusiastic over Dr. Napheys's
works, they certainly possess good points, and should not be
dismissed without some commendation.
BOOKS AND PAMPHLETS RECEIVED.
On Some Common Injuries to Limbs; their Treatment and
After-treatment, including Bone-setting (so called). By Ed-
ward Cotterell, M. R. C. S. Eng., L. R. C. P. Lor.d., etc. With
Illustrations. London: H. K. Lewis, 1885. Pp. x-108.
Hay Fever, and its Successful Treatment by Superficial Or-
ganic Alteration of the Nasal Mucous Membrane. By Charles
E. Sajous, M. D., etc. Illustrated with Thirteen Wood Engrav-
ings. Philadelphia : F. A. Davis, Att'y, 1885. Pp. 103.
A Treatise on Practical Chemistry and Qualitative Inorganic
Analysis, adapted for Use in the Laboratories of Colleges and
Schools. By Frank Clowes, D. Sc. Lond., etc. With Illustra-
tions. From the Fourth English Edition. Philadelphia: Lea
Brothers & Co., 1885. Pp. xiv-376.
The Ten Laws of Health ; or, How Diseases are produced
and prevented: and Family Guide to Protection against Epi-
demic Diseases and Other Dangerous Infections. By J. R.
Black, M. D. Philadelphia: J. B. Lippincott Co., 1885. Pp.
xviii-13 to 413, inclusive. [Price, $2.]
The Pathology and Treatment of Stricture of the Urethra
and Urinary Fistulas. By Sir nenry Thompson, F. R. C. S., M. B.
Lond., etc. Fourth Edition. Philadelphia : P. Blakiston, Son
& Co., 1885. Pp. xii-254. [Price, $2.]
Medical Topics. Containing: 1. Hints aDd Suggestions for
Reform in Medical Education. 2. A Plea for the State Regula-
tion of Medicine and Surgery. 3. Medical Education ; its Ob-
jects and Requirements. By F. R. Sturgis, M. D., Ex-president
of the Medical Society of the County of New York, etc. New
York: William Wood & Co., 1885. Pp. 63. [Price, 25c]
Pneumonia in Young Children. By L. Emmett Holt, A. M.,
M. D., Attending Physician to the Children's Department of the
Northwestern Dispensary, etc. [Reprinted from the " Medical
Record."]
Epilepsy. By L. W. Baker, M. D., Superintendent of a Hos-
pital for Epileptic Children, Baldwinsville, Mass. [Reprinted
from the " Journal of Nervous and Mental Disease."]
Catalogo espanol, clasificado, descriptive) e ilustrado, de los
libros publicados por D. Appleton y Ca. 1885.
Second Annual Report of the New Y"ork Skin and Cancer
Hospital.
Minutes of the Medical Society of Delaware, at its Ninety-
fifth Annual Session.
July 4, 1885.]
L KADI SO
ARTICLES.
17
THE
NEW YORK. MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D Appleton & Co Frank P. Kosteb, M. D.
NEW YORK, SATURDAY, JULY 4, 1885.
THE INTERNATIONAL MEDICAL CONGRESS.
In this issue we conclude our report of the Chicago meet-
ing of the American Medical Association's Committee on the
International Medical Congress. Several of the members of
the Original committee were present and took part in the pro-
ceedings, a fact that can not be otherwise construed than as a
complete recognition on their part — and presumably on the
part of the original committee as a body — of the new commit-
tee's legitimacy.
The enlarged committee, therefore, with power to fill vacan-
cies occurring even among the original members, now consti-
tutes the only body charged with the organization of the Con-
gress. That being the case, its acts assume an importance that
might have been questioned before. We are glad to be able to
say that the convictions which we expressed two weeks ago
have been justified by the moderation and breadth of view
shown at Chicago. Of course, we deplore the fact that the
committee was under compulsion to cut off the heads of a num-
ber of distinguished men whose co-operation the Congress can
ill afford to spare ; and it is humiliating to reflect that this com-
pulsion was not the outgrowth of any spontaneous expression
of feeling on the part of the profession, but merely the natural
sequence of the excitement brought about at New Orleans. It
was none the less real and morally binding, however, and we
readily concede that the committee, whatever may have been
the feelings of its individual members, had no course open to it
hut the very course that it took. When in the future — and,
to judge by the action taken in Philadelphia, in the near future
— it comes to be admitted on all hands that an honest difference
of opinion as to how far a sentiment should be allowed to sway
the policy of the profession ought never to have been magni-
fied into an issue before which every other consideration should
he made to yield, and perverted into a test of personal worth,
it will certainly be recognized that the responsibility for carry-
ing out those monstrous notions to the extent of wantonly
humiliating some of the best men to be found in the ranks of
the medical profession, and at the same time detracting from
the strength of the home representation at a convocation of the
medical men of the whole world, condemnation will not be
visited upon this committee, but upon those whose acts called
it into existence.
The committee, we repeat, is not to be held chargeable with
the crippling of the Congress that must be the result of the
foolish policy settled upon at New Orleans— a policy that has
already begun to bear its bitter fruit, as shown by the action of
our brethren in Philadelphia. The preambles and resolution
adopted by them (for a copy of which we are indebted to the
courtesy of the "Medical News," of Philadelphia) show plainly
that the strong men of the profession in that city are not to be
made the cat's paws of a little knot of agitators. It is signifi-
cant that several of the names signed to the resolution are those
of men appointed to high positions in the new list of officers of
the Congress.
There was only one other main question with which the
committee had to wrestle, and that was the demand for a more
strictly geographical representation in the organization of the
Congress. So far as the proceedings at New Orleans could be
taken as an indication of what was wanted, this demand seemed
much more obtrusive than the feeling on the code question.
There was danger, consequently, that the committee would feel
constrained to take sweeping measures, and to make the officers
of the Congress represent not the medical achievements of the
country, but its territorial districts. We think an examination
of the new list of officers decided upon by the committee will
show that, while it has done all that could fairly be expected of
it by the most exacting stickler for local representation, it has
yet contrived to fill the prominent places with well-known men
— men in every way fitted for the positions to which they have
been appointed. We must therefore congratulate the commit-
tee upon this portion of its work, and we feel convinced that
whatever sense of disappointment may be the portion of those
whose names have been lopped off from the original list will
arise from the thought, not that they as individuals have had
an indignity put upon them, but that they are debarred from
showing their devotion to American medicine on an occasion
when, more than on any other, it would have been conspicuous
and effective. While we praise the work of the committee, we
must confess that the outlook for the Congress is gloomy.
THE EMBRYOLOGICAL RELATIONS OF CONGENITAL MAL-
FORMATIONS OF THE PHARYNX.
At the fourteenth congress of the German Gesellschaft fur
Chirurgie, an excellent digest of the proceedings of which is
published in the form of a supplement to the " Centralblatt fur
Chirurgie," Dr. Albrecht, of Brussels, read a notable paper on
the morphological significance of pharyngeal diverticula. He
sought to establish that, besides the lungs, there were two dif-
ferent sorts of these diverticula in the human subject, namely,
the dorsal, epipharyngeal, or retropharyngeal, and the lateral
or parapharyngeal. The epipharyngeal diverticula of man, he
says, are those which Zenker and von Zietnssen have character-
ized as ''impulse-diverticiila" (Pulsiotwdwertilcel). In all the
cases thus far observed the opening of the larynx, that of the
oesophagus, and that of the diverticulum have all been situated
at the same level. Since a like diverticulum, the so-called oeso-
phageal oiecum of the veterinarians, is found as a normal struct-
ure in several of the Mammalia (constantly in the hog, the
camel, and the elephant, and occasionally in the ox), Albrecht
maintains that Zenker and von Ziemssen'a impulse-diverticula
in man have the morphological significance of atavistic forma-
tions, and are to be referred to the same sources as the oeso-
phageal Cfficnm, which latter, furthermore, he looks upon as a
18
MINOR PARAGRAPHS.
[N. Y. Med. Jodh.,
houiologiie of the air-bladder of fishes, having no homology
with lungs, since there are certain Teleosteans {Diodon, Triodon,
and Tetrodon) that have both lungs and air-bladders, while, on
the other hand, in some of the Selachians (Galeus, Mustelus,
and Acanthias) the air-bladder is found to have the form of an
epipharyngeal diverticulum. Since in the hog, the oesophageal
cascum (Raehentasche) of which was demonstrated with a prep-
aration, the pouch is overlain by the crico-pharyngeus muscle,
and its mucous membrane can be inverted beneath the crico-
pharyngeus with the finger, thus what is known in man as
pharyngocele being produced artificially, we have an explana-
tion of the presence, often recorded in literature, of muscular
fibers on the cranial portion of the impulse-diverticulum in
man, doubted by Zenker and von Ziemssen on theoretical
grounds. The Zenker-von Ziemssen versus Kouig controversy
in regard to these muscular fibers is therefore decided in
Konig's favor, for the cranial portion of the pouch must, under
all circumstances, be covered by the crico-pharyngeus.
In man, the author continues, all the parapharyngeal diver-
ticula have the same morphological significance ; they all origi-
nate in the second post-oral cleft (bounded by the hyal arch,
consisting of the styloid process, the stylo-hyoid ligament, and
the lesser cornu of the hyoid bone, and the ventral rudiment of
the first branchial arch, the greater cornu of the hyoid bone),
the cutaneous opening of which is closed, while the blind termi-
nation thus formed is dilated into a pouch. To the same mode
of origin we must refer congenital cervical fistulas, and con-
genital hydroceles, atheromas, and dermoid cysts of the neck.
If the second post-oral cleft does not close at all, a congenital
cervical fistula is the result ; if its cutaneous opening closes, an
internal incomplete fistula is formed, which, if its lateral blind
end bulges, gives the impression, as in a case cited from Wat-
son, of a lateral diverticulum of the pharynx ; if both the cuta-
neous and the pharyngeal openings close, either a hydrocele, an
atheroma, or a dermoid cyst is developed, according as the con-
tents are serous, pultaceous, or containing dermoid formations,
such as hair and teeth.
Like congenita] fistulas of the neck, the parapharyngeal di-
verticula lie mediad of the sterno-cleido-mastoid muscle, making
their way first between the external and the internal carotid
arteries, then between the glossopharyngeal nerve and the
stylo pharyngeus muscle, to open finally into the pharynx be-
hind the pharyngo-palatine arch. The reason why the cutane-
ous orifice of a congenital cervical fistula and the blind end of a
pharyngeal diverticulum lie close above the sterno-clavicular
joint is to be found in the cranio-caudad migration of the two
respectively, a migration which tallies with the caudad migra-
tion of the stomach, the heart, and the aortic arch ; and the
single explanation lies in the fact that, instead of the twenty-
first spinal nerve, a cranial nerve goes to the stomach in man,
and the inferior laryngeal nerve makes a turn two feet long, in
the adult, around the fourth aortic arch (the arch of the aorta
on the left, and the innominate artery and the proximal portion
of the subclavian on the right side) before reaching the laryn-
geal muscles to which it is distributed. The author considers
that the larynx, the air-passages, and the lungs constitute a
normal hypopharyngeal diverticulum.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Health- Department for the following
statement of cases and deaths reported during the two weeks
ending June 30, 1885 :
Week ending June 23.
Week ending J Line 3"-
DISEASES.
Cases.
Deaths.
Caees.
Deaths.
7
1
13
4
54
7
29
1
Cerebrospinal meningitis . . .
2
2
1
1
89
17
100
25
57
23
63
3"5
The American Medical Association's Committee on the
International Medical Congress. — Chicago, June 25th. — The
meeting of to-day was called to order by the Chairman, Dr.
Cole, at 9.20 a. m. The minutes of yesterday's meeting were
read and adopted. Dr. R. Battey offered the following pre-
amble and resolution :
Whereas, It is expedient that the meetings of this committee
shall represent, as far as practicable, the profession of all por-
tions of our country,
Resolved, That any member of the committee who may be
unable to attend a meeting shall be empowered to send as his
proxy for the meeting any member of the American Medical
Association in good professional standing, and a resident of his
State or member of his Government Department. Adopted
unanimously.
Chairman Scott, of the sub-committee appointed yesterday,
stated that the secretary would read this committee's report
before its adoption, as it had been placed in his hands. Some
general remarks were made as to the method of adopting the
rules, and it was decided to act on them seriatim. The result
of this action was that most of the rules reported by the com-
mittee were adopted, some amendments being made to a few of
them. As they can not be given with exactness until after the
committee's final revision, it is thought best not to attempt to
incorporate them in this report. It is sufficient to say at pres-
ent that Rule I was so amended as to guard against the partici-
pation of irregular practitioners in the meetings of the Con-
gress.
That portion of the committee's report which had reference
to the list of officers for the Congress contained the following
nominations: For president, Austin Flint, of New York. For
vice-presidents, N. S. Davis, of Chicago; H. F. Campbell, of
Augusta, Ga. ; R. P. Howard, of Montreal. Canada ; T. G.
Richardson, of New Orleans; A. Stille, of Philadelphia; W. 0.
Baldwin, of Montgomery, Ala. ; H. M. Skillman, of Lexington,
Ky. ; L. A. Sayre, of New York; W. W. Dawson, of Cincin-
nati; J. M. Toner, of Washington; W. Brodie, of Detroit; J.
L. Atlee, of Lancaster, Pa. ; and O. W. Holmes, of Boston.
For secretary-general, John Packard, of Philadelphia. For
chairman of the Finance Committee, F. S. Dennis, of New
YTork. For members of the Committee of Arrangements (those
whose names are printed in italics being also members of the
executive sub-committee) :
George A. Ketchum, Mobile; D. A. Linthicum, Helena,
Ark. ; R. B. Cole (chairman), San Francisco ; Charles Deni-
son, Denver, Col.: W. C. Wile, Sandy Hook, Conn.; W. E.
Duncan, Dakota Territory; L. P. Bush, Wilmington, Del.; A.
Y. P. Garnett, Washington ; R. D. Murray, Moultrie, Pa. ;
Robert Battey, Rome, Ga. ; E. P. Cook, Mendota, 111. ; F. W.
July 4, 1885.J
MINOR PARAGRAPHS.
19
Beard, Vincennes, Ind.; W. Watson, Dubuque, Iowa; D. W.
Stonnont, Topeka, Kan.; W. H. Wathen, Louisville; J. W.
Dupree, Baton Rtmge; S. 0. Gordon, Portland, Me. ; S. Lynch
(vice-chairman), Baltimore ; A. H. Wilson, South Boston, Mass. ;
A. R. Smart, Hudson, Mich.; George F. French, Minneapolis;
J. M. Taylor, Corinth, Miss. ; N. F. Essig, Plattsburg, Mo. ;
R. C. Moore, Omaha; J. W. Parsons, Portsmouth, N. H. ;
William Pierson, Orange, N. J. ; Ellsworth Eliot, New' York ;
X. C. Scott, Cleveland ; E. P. Fraser, Portland, Oregon ; J. V.
Shoemaker (secretary), Philadelphia; W. E. Anthony, Provi-
dence; R. A. Kinloch, Charleston; F. L. Sim, Memphis; J. W.
McLaughlin, Austin ; E. T. Upham, West Randolph, Vt. ; W.
C. Dabney, Charlottesville, Va. ; G. Baird, Wheeling, W. Va. ;
Nicholas Senn, Milwaukee ; J. J. McAchran, Laramie City, Wyo-
ming Territory; J. B. Hamilton, Washington; Robert Murray,
TJ. S. Army, Washington ; F. M. Gunnel!, U. S. Navy, Washing-
ton; W. Pierson; J. S. Billings, U. S. Army; J. M. Brown,
U. S. Navy; I. M. Hays, Philadelphia; H. F. Campbell, Au-
gusta, Ga. ; C. Johnston, Baltimore ; J. W. S. Gouley, New
York; L. A. Say re, New York; G. J. Engelmann, St. Louis;
F. S. Dennis, New York ; and J. Packard, Philadelphia. For
Local Committee of Arrangements : A. Y. P. Garnett (chair-
man), J. S. Billings, S. O. Ritchie, and Frank Baker, all of
Washington, with power to add to their number any of the
physicians of Washington in good standing. For officers of
sections: Section I {Medical Education, Legislation, and Regis-
tration).— President, S. E. Chaille, New Orleans. Vice-presi-
dents: G. Capples, San Antonio, Tex.; R. J. Dunglison, Phila-
delphia. Secretaries: E. F. Dunbar, Boston; Trail. Green,
Easton, Pa. Council : H. D. Didama, Syracuse, N. Y. ; D. C.
Gilman, Baltimore; J. F. Harrison, University of Virginia ; C.
A. Lindsley, New Haven ; W. Pepper, Philadelphia ; J. F. Prio-
leau, Charleston ; L. McL. Tiffany, Baltimore ; II. Gibbons, San
Francisco ; J. A. Dibbrell, Jr., Little Rock, Ark. ; C. L. Allen,
Rutland, Vt. ; H. O. Hitchcock, Kalamazoo, Mich. ; R. H. Reed,
Mansfield, 0. ; J. W. Bailey, Gainesville, Ga. ; K. Wylie, San-
ford, Fla. Section II {Anatomy). — President, J. Leidy, Phila-
delphia. Vice-presidents: W. Pancoast, Philadelphia; C. W.
Kelley, Louisville ; S. Logan, New Orleans. Secretaries: W. W.
Keen, Philadelphia; G. E. de Schweinitz, Philadelphia. Council :
H. Allen. Philadelphia ; F. Baker, Washington ; A. Henson,
Philadelphia; T. Dwight, Boston; F. L. Parker, Charleston;
C. T. Parkes, Chicago; T. T. Sabine, New York; N. Senn,
Milwaukee ; J. F. Shepherd, Montreal ; R. W. Shufeldt, U. S.
Army; G. Halley, Kansas City; S. W. Craft, Jackson, Miss.
Section III {Physiology). — President: J. C. Dalton, New York.
Vice-presidents: H. P. Bowditch, Boston ; J. F. Hibberd, Rich-
mond, Ind.: H. N. Martin, Baltimore; M. Michel, Charleston.
Secretary : J. G. Curtis, New York. Council : G. Baumgarten,
St. Louis; H. G. Beyer, U. S. Navy ; A. Flint, Jr., New York;
W. Lee, Washington; J. J. Mason, Newport, R. I. ; II. Sewall,
Ann Arbor, Mich.; W. F. Hyer, Holly Springs, Mich.; J. H.
Wyeth, San Francisco; A. D. Brubaker, Philadelphia ; A. F.
Whelan, Hillsdale, Mich.; T. S. Latimer, Baltimore; S. Putnam,
Montpelier, Vt. ; C. H. A. Kleinschmidt, Washington. Section
IV {Pathology). — President: F. Delafield, New York. Vice-
president: W. Pepper, Philadelphia. Secretaries: H. M. Briggs,
New York; W. II. Welch, Baltimore; I. N. Himes, Cleveland.
Council: C. Fenger, Chicago; R. H. Fitz, Boston; E. G. Jane-
way, New York ; J.B.Johnson, St. Louis; G. M. Sternberg,
H. S. Army; W. F. Whitney, Boston ; C. H. Hunter, Minneapo-
lis; E. O. Shakespeare, Philadelphia; II. Schmidt, New Orleans;
M. Longstretb, Philadelphia. Section V {Medicine — including
the original section in Nervous Diseases and Psychiatry. — Presi-
dent: J. M. DaCosta, Philadelphia. Vice-presidents: vVlonzo
Clark, New York; J. B. McCaw, Richmond; C. F. Folsom,
Boston ; J. P. Gray, Utica, N. Y. ; J. S. Jewell, Chicago ;
R. McSherry, Baltimore; A. B. Palmer, Ann Arbor, Mich.; T.
F. Rochester, Buffalo; S. W. Mitchell, Philadelphia; P. G.
Robinson, St. Paul. Secretaries : W. Osier, Philadelphia : J.
T. Whittaker, Cincinnati ; W. Hay, Chicago. Council : R. Bar-
tholow, Philadelphia ; F. T. Miles, Baltimore ; S. G. Webber,
Boston ; J. P. Logan, Atlanta ; F. B. Lester, Kansas City ; A.
B. Arnold, Baltimore ; E. D. Ferguson, Troy, N. Y. ; S. C.
Chew, Baltimore ; W. H. Geddings, Aiken, S. C. ; W. W. John-
ston, Washington; G. A. Ketclium, Mobile; F. Minot, Boston;
B. Robinson, New York ; J. Burnett, Cleveland ; W. W. Cleav-
er, Lebanon, Ky. ; W. H. Phillips, Canton, O. ; S. S. Clark, St.
Albans, Vt. ; G. Williamson, Ottawa, Canada ; J. Draper, Brat-
tleboro, Vt. ; E. Grissom, Raleigh, N. C. ; P. Brice, Tuscaloosa,
Ala. Section VI {Surgery). — President: D. W. Yandell, Louis-
ville. Vice-presidents: D. H. Agnew, Philadelphia; W. T.
Briggs, Nashville ; S. W. Gross, Philadelphia ; W. H. Hingston,
Montreal ; R. A. Kinloch, Charleston ; E. M. Moore, Roches-
ter ; M. Gunn, Chicago. Secretaries : J. C. Warren, Boston ;
I). P. Allen, Cleveland. Council : J. Ashhurst, Jr., Phila-
delphia; D. W. Cheever, Boston; P. S. Conner, Cincinnati;
G. E. Fenwick, Montreal ; F. II. Gerrish, Portland, Me. ;
J. C. Hutchison, Brooklyn ; C. Johnston, Baltimore ; T. M.
Markoe, New York; A. P. Smith, Baltimore; J. F. Thompson,
Washington; T. R. Varick, Jersey City ; H. H. Mudd, St. Louis ;
J. R. Weist, Richmond, Ind. ; J. P. Wall, Tampa, Fla. ;
Mercer, Omaha ; H. Bingham, Burlington, Vt. ; T. A. Dunsmore,
Minneapolis; J. T. Carpenter, Pottsville, Pa.; W. S. Janney,
Philadelphia; J. Garretson, Philadelphia; I. N. Quimby, Jersey
City; T. A. McGraw, Detroit; Russell, , Wis.; J. H.
Rawson, Burlington, la.; H. W. Austin, TJ. S. Marine-Hospital
Service; O. Coskery, Baltimore; W. T. Andrews, Mitchell,
Dak. ; H. H. Smith, Philadelphia ; Westmoreland, Scran-
ton, Pa. Section VII {Obstetrics and Gynaecology). — President:
R. Battey, Rome, Ga. Vice-presidents: W. T. Howard, Balti-
more; R. B. Maury, Memphis; J. C. Reeve, Dayton, O. ; A. II.
Smith, Philadelphia ; T. A. Reamy, Cincinnati ; T. G. Thomas,
New York; W. H, Byford, Chicago; H. P. C. Wilson, Balti-
more; J. Goodman, Louisville; W. P. King, Sedalia, Mo. Sec-
retaries: T. Opie, Baltimore; J. R. Chad wick, Boston; G.J.
Engelmann, St. Louis. Council: R. P. Harris, Philadelphia; A.
F. A. King, Washington ; E. Van de Warker, Syracuse; W. T.
Lusk, New York; R. S. Sutton, Pittsburgh; T. Parvin, Phila-
delphia; R. Glisan, Portland, Oregon; J. Scott, San Francisco.
0. V. Northam, Lawrence, Kansas ; E. P. Sale, Aberdeen,
Miss.; W. Varian, Titusville, Pa.; T. B. Harvey, Indianapolis;
E. Warner, Worcester, Mass.; L. Fay, Lowell, Mass.; D.
Crea, Council Bluffs, Iowa; B. E. Hadra, San Antonio, Tex. ;
L. Robinson, San Francisco ; E. S. Dunster, Ann Arbor, Mich. ;
H. O. Marcy, Boston; T. Opie, Baltimore; W. H. Baker,
Boston; W. Gardner, Montreal; W. Goodell, Philadelphia;
A. R. Jackson, Chicago; J. T. Johnson, Washington. Section
VIII {Ophthalmology). — President: E. Williams, Cincinnati.
Vice-presidents: II. D. Noyes, New York; E. L. Holmes, Chi-
cago; W.Thomson, Philadelphia. Secretary: S. M. Burnett,
Washington. Council: C. S. Bull, New York; A. W. Calhoun,
Atlanta; H. Derby, Boston; E. G. Loring, New York; W. F.
Norris, Philadelphia; W. W. Seely, Cincinnati; S. Theobald,
Baltimore; 0. F. Wadsworth, Boston; II. W. Williams, Bos-
ton ; J. Green, St. Louis; P. I). Keyser, Philadelphia; D. Hunt,
Boston ; B. J. Jeffries, Boston ; A. G. Sinclair, Memphis ; B.
Baldwin, Montgomery, Ala.; W. II. Sanders, Mobile; B. E.
Frier, Kansas City ; E. Smith, Detroit ; J. L. Thompson, In-
dianapolis. Section IX {Otology). — President: C. J. Blake,
Boston. Vice-presidents: A. M. Wilder, San Francisco; II. N.
Spencer, St. Louis ; D. S. Reynolds, Louisville. Secretary : S.
20
MINOR PA
RAORA PUS.
[N. Y. Med. Joiik.,
O. Ritchie, Washington. Council: J. II. White, Richmond; J.
O.Green, Boston; G. Strawbridge, Philadelphia.; S.J.Jones,
Chicago; C. Turnbull, Philadelphia; J. A. Lippincott, Pitts-
burgh; C. II. Burnett, Philadelphia; C. J. Lundy, Detroit; E.
II. Ilazen, Davenport, Iowa. Section X (Dermatology and
Syphilis). — President: W. A. I lard a way, St. Louis. Vice-
presidents: J. M. Keller, Hot Springs, Ark.; J. N. Hyde, Chi-
cago; J. C. White, Boston; L. A. Dubiin^r, Philadelphia.
Secretaries: F. E. Daniel, Austin, Tex.; W. T. Carlett, Cleve-
land. Council: I. E. Atkinson, Baltimore; A. R. Roliinson,
New York; E. Wigglesworth, Boston ; H. C. Yarrow, Wash-
ington; II. 0, Walker, Detroit; W. F. Glenn, Nashville; H. R.
Carter, U. S. Marine-Hospital Service ; J. J. McAchran, Lara-
mie City, W. T. ; J. A. Octerlony, Louisville; LeG. B. Dens-
low, St. Paul. Section XI (Laryngology). — President: J. N.
Mackenzie, Baltimore. Vice-presidents: M. F. Coomes, Louis-
ville : F. I. Knight, Boston. Secretaries : D. Bryson Delavan,
New York; E. F. Ingals, Chicago. Council: W. II. Daly,
Pittsburgh; G. W. Major, Montreal; E. C. Morgan, Washing-
ton; W. Porter, St. Louis; E. L. Shurly, Detroit; R. P. Lin-
coln, New York; C. Sajous, Philadelphia; H. Goldthwaite,
New York. Section XII (Public and International Hygiene).
— President: H. A. Johnson, Chicago. Vice-presidents: A. L.
Carroll, Albany; J. L. Cabell, University of Virginia; J. B.
Lindsley, Nashville; J. E. Reeves, Wheeling; J. N. McCormick,
Bowling Green, Ky. Secretaries: W. Wyman, U. S. Marine-
Hospital Service; G. H. Rohe, Baltimore. Council: A. Gihon,
U. S. Navy ; H. B. Baker, Lansing, Mich. ; G. P. Conn, Con-
cord, N. H. ; W. H. Ford, Philadelphia; H. Leffmann, Phila-
delphia; D. W. Hand, St. Paul; J. H. Kidder, Washington; J.
H. Rauch, Springfield, III.; J. H. Raymond, Brooklyn; J. R.
Smith, U. S. Army; S. Smith, New York; H. P. Wolcott,
Cambridge, Mass. ; G. B. Thornton, Memphis ; R. M. Swer-
ingen, Austin, Tex. ; C. M. Hewitt, Red Wing, Minn. ; II. F.
Lester, Detroit; E. S. Elder, Indianapolis; O. C. DeWolff,
Chicago; E. L. B. Godfrey, Camden, N. J.; H. S. Orme,
Los Angeles, Cal. ; J. Holt, New Orleans; W. S. Robinson,
Musratine, Iowa; W. L. Schenck, Osage City, Kansas; B. Lee,
Philadelphia. Section XIII (Collective Investigation, Nomen-
clature, Vital Statistics, and Climatology). — President: N. S.
Davis, Chicago. Vice-presidents: J. Cochran, Mobile; E. M.
Snow, Providence. Secretary : J. F. Todd, Chicago. Council:
N. Allen, Lowell, Mass.; R. A. Cleeman, Philadelphia; J. H.
Hollister, Chicago; J. T. Reeve, Appleton, Wis.; J. Tyson,
Philadelphia ; E. T. Sabal, Jacksonville, Fla. ; A. C. Hamlin,
Bangor, Me. ; T. S. Hopkins, Thomasville. Ga. ; T. J. Allen,
Shreveport, La. ; C. Denison, Denver ;' H. C. Ghent, Austin,
Tex. ; E. P. Hurd, Newburyport, Mass. ; E. W. Morley, Cleve-
land; O. W. Wight, Detroit; T. T. Miner, Seattle, Wash. T. ;
P. C. Remondino, San Diego, Cal. ; J. W. Parsons, Portsmouth,
N. H. ; W. P. Hart, Washington, Ark. Section XIV (Military
and Naval Surgery and Medicine). — President: D. L. Hunting-
ton, U. S. Army. Vice-presidents: F. H. Hamilton, New York;
H. McGuire, Richmond ; S. P. Moore, Richmond ; W. E. Tay-
lor, U. S. Navy (retired) ; P. O. Hooper, Little Rock, Ark. ; E.
Andrews, Chicago; E. H. Gregory, St. Louis; D. McLane, De-
troit. Secretaries : B. F. Pope, U. S. Army ; McF. C. Gaston,
Atlanta. Council: D. Bloodgood, U.S. Navy; R. B. Bonte-
cou, Troy, N. Y. ; J. H. Brinton,. Philadelphia; E. J. Marsh.
Paterson, N. J.; C. M. Mastin, Mobile; G Peck, U. S. Navy;
W. F. Peck, Davenport, Iowa; C. Smart, U. S. Army; J. R.
Tryon, U. S. Navy; A. A. Woodhull, U. S. Army; J. W. Ham-
ilton, Columbus, O.; W. Murphy, St. Paul; W. C. B. Fifield,
Boston ; E. Goodman, U. S. Army ; W. S. Tremaine, U. S. Army ;
J. II. Peabody, Omaha; S. T.Armstrong, U.S. Marine-Hospital
Service. Section XV (Practical and Experimental Therapeu-
tics).— President: II. C. Wood, Philadelphia. Vice-presidents: E.
R. Squibb, Brooklyn ; R. T. Edes, Boston ; F. P. Porcher, Churl. -
ton. Secretaries: R. T. Reichert, Philadelphia; R. M.Smith,
Philadelphia. Council : G. Griswold, New York; R. Amory, Bos-
ton ; II. M.Lyman, Chicago; S. Nickels. Cincinnati: F. Steyart,
Cincinnati ; I. Ott, Easton, Pa. ; D. W. Prentiss, Washington ; C.
Rice, New York ; C. II. White, U. S. Navy ; T. F. Wood,Wihiiing-
ton, N.C.; J. M. Flint, U. S. Navy; E. P. Fraser, Portland,
Oregon; T. F. Breck, Springfield, Mass.; R. D. Webb, Living-
ston, Ala.; F. Woodbury, Philadelphia; J. V. Van Velsas,
Yankton, Dakota T. ; Codlock, Knoxville, Tenn. ; J. F. Y.
Payne, Galveston, Tex. ; T. Weed, Cleveland; D. W. C. Wade,
Holley, Mich.; R. C. Moore, Omaha; G. M. Garland, Boston;
Crompton, Lancaster, Pa. Section XVI (Diseases of Chil-
dren).— President: J. L. Smith, New York. Vice-presidents:
D. Miller, Chicago; S. C. Busey, Washington. Secretary: E.
T. Williams, Boston. Council: F. Forchheimer, Cincinnati; J.
M. Keating, Philadelphia ; W. Lee, Baltimore; J. H. Pope,
Marshall, Tex.; W. B. Atkinson, Philadelphia; A. Walker,
Evansville, Ind. ; W. A. Conklin, Dayton, O. ; W. F. Holt, Ma-
con, Ga. ; K. Johnson, Grand Rapids, Mich. ; C. A. Leale, New
York; S. II. Charlton, Seymour, Ind.; W. II. Dougherty, Au-
gusta, Ga. ; B. II. Riggs, Selma, Ala. ; H. H. Middlekamp, Iron-
ton, Mo. ; J. A. Hodge, Henderson, Ky. ; G. W. Moody, Huron,
Dakota T. ; A. A. Horner, Helena, Ark.
Dr. W. II. Wathen offered the following preamble and reso-
lution : .
Whereas, It has become necessary, in order that this com-
mittee may fully understand the professional and personal
standing of the various persons suggested for appointment,
therefore be it
Resolved, That it is the sense of this meeting that all remarks
bearing upon the qualifications of said persons be considered as
strictly confidential between the members of the committee,
and that the report of such remarks, if heretofore recorded, be
expunged from the minutes. Carried unanimously.
The committee then adjourned, to meet in St. Louis on the
Monday preceding the next meeting of the American Medical
Association.
New York State Medical Association, Northern Branch.
— The first annual meeting will be held in Utica on Tuesday, the
7th instant. The following papers are expected to be read :
"Well-water and its Uses," by Dr. Malek A. Southworth, Little
Falls ; " The Treatment of Haemorrhoids by Recent Methods
and Instruments," by Dr. Leroy J. Brooks, Norwich ; " Extra-
uterine Pregnancy," by Dr. William A. Hall, Fulton; "Anky-
losis of the Knee Joint as a Remedy for Extreme Paralysis of
the Leg, due to Infantile Paralysis," by Dr. Stephen Smith, New
York; "The Advantages of Paris as a Place of Medical Educa-
tion," by Dr. M. M. Bagg, Utica; " Jaborandi and its Uses in
TypLoid Fever," by Dr. Wallace Clarke, Utica.
The District Medical Society for the County of Hudson,
N. J., will meet at the Stevens Institute, in Hoboken, on Tues-
day, the 7th inst., at 3 o'clock p. m. Dr. W. P. Watson will
read a paper on Cholera Infantum, and Dr. J. Lewis Smith and
Dr. J. H. Ripley, of New York, are expected to take part in
the discussion.
The International Medical Congress and the Medical
Profession of Philadelphia. — A meeting of the members of the
medical profession of Philadelphia concerned in the organiza-
tion of the International Medical Congress of 1887 was held at
the Hall of the College of Physicians, on Monday, June 29th,
Dr. Alfred Stille in the Chair. Dr. David W. Yandell, of Louis-
ville, was present by invitation.
July 4, 1885.1
PROCEEDINGS OF SOCIETIES.
21
After hearing a report of the proceedings of the new com-
mittee, at the meeting held in Chicago last week, and, after con-
sidering the changes in the organization which were made, in-
cluding the restriction of the scope of the membership, by which
a large proportion of the profession of the country would be
excluded from the Congress, the following preambles and reso-
lution were unanimously adopted :
Whereas, Certain serious changes have been recently effected in the
preliminary organization and rules for the International Medical Con-
gress of 1887, it has seemed desirable for the members of the General
Committee and the officers of the Sections resident in Philadelphia to
meet for consultation ; and
Whereas, It has appeared that these changes are inconsistent with
the original plan, and detrimental to the interests of the medical pro-
fession in America, and of the International Medical Congress ; there-
fore be it
/■ Resolved, That we, the undersigned, consider tbat our duty to the
profession and to ourselves requires us to decline to hold any office
whatsoever in connection with the said Congress as now proposed to be
organized:
D. Hayes Agnew, S. Weir Mitchell,
Roberts Bartholow, William F. Norris,
John H. Brinton, William Gsler,
Charles H. Burnett, John H. Packard,
R. A. Cleemann, Theophilus Parvin,
J. M. Da Costa, William Pepper,
Louis A. Duiiring, Edward T. Reiciiart,
William H. Ford, Albert H. Smith,
William Goodell, Robert Meade Smith,
Samdel W. Gross, Alfred Stille,
Robert P. Harris, George Strawbridge,
I. Minis Hays, William Thomson,
William W. Keen, James Tyson,
Joseph Leidy, Horatio C. Wood,
David W. Yandell.
Armyllltelligen.ee. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from June 21, 1885, to June 27, 1885 :
Haetstjff, Albert, Major and Surgeon. Assigned to duty at
Fort Hamilton, New York Harbor. S. O. 133, Department
of the East, June 24, 1885.
Middleton, J. V. D., Major and Surgeon. Granted one
month's leave, with permission to apply for fifteen days'
extension, to take effect about the 15th proximo. S. O. 88,
Department of the Missouri, June 19, 1885.
Brown, H. E., Major and Surgeon. Assigned to duty as post
surgeon, Fort Reno, Indian Territory. S. 0. 91, Depart-
ment of the Missouri, June 24, 1885.
Taylor, Blair D., Captain and Assistant Surgeon. Ordered
from Department of Texas to Department of the East. S. O.
141, A. G. O., June 20, 1885.
Caster, William F., Captain and Assistant Surgeon. Ordered
from Department of the East to Department of Texas. S.
O. 141, A. G. 0., June 20, 1885.
Davis, William B., Captain and Assistant Surgeon. Leave of
absence extended three months. S. O. 142, A. G. 0., June
23, 1885.
Ebert, R. G., First Lieutenant and Assistant Surgeon. Granted
leave of absence for one month, to take effect about July
5th. S. O. 97, Department of the Columbia, June 17, 1885.
Robertson, R. L., First Lieutenant and Assistant Surgeon.
Now on leave of absence, directed to report in person by
July 7, 1885, to commanding officer, Columbus Barracks,
Ohio, to accompany detachment of recruits to Department
of Texas. On completion of this duty, to rejoin his proper
station. S. 0. 143, A. G. O., Juno 24, 1885.
Society Meetings for the Coming Week :
Monday, Jluy 6th : New York Academy of Sciences (Section
in Biology); Morrisania Medical Society (private); Brook-
lyn Anatomical and Surgical Society (private) ; Utica, N. Y.,
Medical Library Association; St. Albans, Vt., Medical As-
sociation ; Providence, R. L, Medical Association ; Hartford
City, Conn., Medical Association; Chicago Medical Society.
Tuesday, July 7th : Elmira, N. Y., Academy of Medicine; Buf-
falo Medical and Surgical Association ; Medical Society of
the County of Broome, N. Y. ; Ogdensburg, N. Y., Medi-
cal Association; Hudson County (Jersey City) and Union
County (quarterly), N. J., Medical Societies; Chittenden
County, Vt., Medical Society; Androscoggin County, Me.,
Medical Association (Lewiston).
Wednesday, July 8th : American Microscopical Society of the
City of New York ; Medical Societies' of the Counties of
Cayuga and Seneca (annual). N. Y. ; Tri-States Medical As-
sociation (Port Jervis, N. Y.) ; Franklin District (quarterly
— Greenfield), Hampshire District (quarterly — Northamp-
ton), and Worcester District, Mass. (Worcester), Medical So-
cieties.
Thursday, July 9th : Brooklyn Pathological Society ; Medical
Society of the County of Fulton, N. Y. (semi-annual — Johns-
town); South Boston, Mass., Medical Club (private).
Friday, July 10th: Medical Society of the Town of Saugerties,
N. Y.
Saturday, July 11th: Worcester North District, Mass., Medi-
cal Society.
proceebings of Societies,
COLLEGE OF PHYSICIANS OF PHILADELPHIA.
Meeting of June 3, 1885.
A Plea for the Medicinal Use of Pure Alcohol and Al-
coholic Mixtures of Known Composition in Preference to
Ordinary Fermented Liquids.— Dr. Henry Leffmann read
the following paper:
I present to the College this evening, with some misgivings,
I confess, a topic which can scarcely yet be considered a "live
issue " in clinical medicine, but which is destined, I am certain,
to become one. At the present time the profession does not
take kindly to suggestions having in view material modifica-
tions of its policy in reference to alcoholic liquors. The ma-
jority of physicians regard those who preach or practice total
abstinence, or throw doubt on the indispensability of alcohol
as a therapeutic agent, as entitled to little respect or tolerance.
In presenting the view that we should abandon in clinical medi-
cine the use of the natural wines and liquors, and resort to
mixtures confessedly fictitious, we must expect to encounter all
the force of the conservative spirit. Many centuries of con-
stant use have developed in the race a feeling that fermented
drinks, particularly those that, like wines and malt liquors,
have suffered no modification by distillation or admixture, are
bounties of nature wisely given for our use. The traditions of
the past associate the first preparation of liquor with the godsr
and in all ages poetry and prose have combined to increase the
reverence for these natural products. Yet all this feeling is
nothing but a superstition. Fermentation is now known to be
a process occurring under the influence of micro-organisms, and
it allies itself with ordinary putrefaction. The reverence which
we have for " Nature's laboratory " is born of ignorance, and
22
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jock.,
there is no progress in chemistry more gratifying in its results
than that which deals with dispelling the illusions which have
surrounded its application to medicine.
"Whatever ulterior relations the plan advocated here may
have to the questions of total abstinence are not presented for
discussion ; I merely offer it as a contribution to the methods
of exactness and certainty in clinical work.
In the medicinal and dietetic use of fermented liquors, it is
the effect of the ethyl alcohol which is sought to be obtained.
It is true that those who prescribe liquors a great deal are in
the habit of saying that the accessory ingredients, compound
ethers, astringents, or bitter principles, etc., are also efficacious,
but that, if we closely observe the customs of such prescribers,
it will be found not only that the effect expected from the
alcohol outweighs that to be obtained from any other ingre-
dient, but also that, in the majority of cases, the accessory in-
gredients are either not known or recognized.
Taking this fact, then, as a starting point, that an agent uni-
versally recognized as one of powerful physiological activity
should be used only in the most definite condition. The forms
of fermented liquors are numerous, and each form is subject to
minor variations, depending on locality and season. The de-
mand exceeds the supply, and hence the strong temptntion to
dilute and substitute. "Within the past few months further no-
tice has been given of the communications by American consuls
abroad to the effect that the wines and brandies exported from
France and Portugal are fictitious articles, in the majority of
cases, and it needs but a little inquiry to show that a very large
trade in liquors more or less spurious is carried on over the en
tire world.
Chemical analysis still has much to accomplish in the study
of fermented liquors, but enough is known to enable us to imi-
tate their essential features. The tabular statement of compo-
sition gives us a long list of mineral ingredients, but we are rea-
sonably certain that, besides the ethyl alcohol, the only ingre-
dients that need attention are the traces of fusel oil, compound
ethers, astringent and bitter principles, and the effect even of
their accessories is often more on the mind than on the body.
I suggest first, then, that in all cases in which the general
physiological effect of ethyl alcohol is desired, it should be given
hy prescription, in the form of a rectified spirit of standard
strength. My friend, Dr. A. W. Miller, who is familiar witb
this topic, both from the point of view of the pharmacist and
physician, has suggested that such a standard, pure spirit be
made officinal under the title spiritus maydis rectvficatus. Such
a suggestion is in the interest of clinical accuracy and safety to
the patient. If the medical profession have any concern in the
protection of the health and morals of the community — and it
would certainly appear that it has great concern — no better op-
portunity ia offered for good work than in reforming the wide-
spread errors in reference to the use of alcoholic liquors. Where
is the physician who would say to a patient, Take a little lauda-
num or chloral every day, and leave to the patient or the drug-
gist the duty of determining the dose, or the duration of the
treatment? Yet every day physicians give similar recommenda-
tions in regard to liquors. The use of rectified spirits in pre-
scriptions is to be recommended on the same ground that we
give potassium bromide and iodide in accurate dosage, instead
of the sea-water which contains them, or morphine and quinine
instead of opium and Peruvian bark. Incidental to the thera-
peutic accuracy and moral safety which are involved in such
practice is the not unimportant question of cheapness. Many
liquors command prices far above the actual commercial value
of the ingredients they contain. A pure French brandy, for in-
stance, costs twelve dollars a gallon. Its place can be taken by
a spirit of much less cost.
Several objections may be made to the plan of using the
plain spirit. I can not stop to consider the one which arises
from a belief in the superiority of a natural product, from a
view that that which arises from a natural process will be
necessarily superior to anything artificial ; this, as I have said
before, is a superstition ; but there are some suggestions which
are really important. It may be that the accessory ingredients
have some therapeutic value, and it has been said to me that
while pure alcohol may easily be used during acute disease and
in hospital practice, that in long-continued treatment, and as a
dietetic, patients can not be made to take it. In these cases the
method to be pursued is plain. Let the alcohol be mixed with
suitable accessory ingredients. If a combination of bitter tonic,
sedative, and stimulant is wanted, it can be prescribed, and so
on. There need be no difficulty in the matter, because modern
art in the preparation of fictitious liquors has reached such per-
fection that excellent imitations of the natural liquors are made,
and these have the advantage of definite and known composi-
tion and greater cheapness.
It is not uninteresting to note here the general nature of
this work. I have the samples to illustrate it. In the prepara-
tion of fictitious liquors three methods maybe employed. 1.
The genuine liquor may be diluted with a suitable strength of
pure spirit. This will give us a liquor differing but little from
the original. 2. The liquor may be imitated by adding to
pure spirit coloring and flavoring ingredients. In many cases
this will give a liquor substantially identical with the original.
3. The liquor may be made up weak, and then taste and appear-
ance of alcoholic strength be given by means of pepper and
bead oil. The latter method is reprehensible, but the two for-
mer methods are, I hold, not injurious, and should be recog-
nized.
OBSTETRICAL SOCIETY OF PHILADELPHIA.
Meeting of June 4, 1885.
The President, Dr. B. F. Baer, in the Chair;
Dr. W. H. H. Githens, Secretary.
Biniodide of Mercury as a Disinfectant in Obstetrics.—
Dr. E. P. Bernardy read a paper with this title. His attention
had first been called to the use of the biniodide of mercury as a
germicide by Dr. Miquel, who had published in "L'Annuaire
met6orologique de Montsouris" the results of some experiments
made to determine the minimum amount of a disinfectant ne-
cessary to prevent fermentation in a litre of sterilized beef-broth.
His experiments showed that the mercurials were the best anti-
septics, the biniodide being nearly three times as strong as the
bichloride. In his table of disinfectants he placed the bichloride
fourth on the list. To a litre of sterilized beef-broth he found
it required 0-025 gramme of the biniodide of mercury to keep
the broth pure, while 0-070 gramme of the bichloride of mer-
cury was necessary to produce like effects. This showed that
bacterial life was impossible in a solution of one forty-thou-
sandth part of the biniodide, while of the bichloride it required
one fourteen-thousandth part. The reader had been so forcibly
impressed with these experiments that he had determined to
give the biniodide of mercury a trial in obstetric cases where it
was necessary to use an antiseptic. The following were the
cases in which it had been used :
Case I. — On February 7, 1885, he was requested to take charge
of Mrs. D., who had been confined about six weeks previously. It
had been her second confinement, the duration of labor had been
short and delivery natural, but an extensive laceration of the peri-
naeum had occurred. No attempt had been made to bring the
parts together by sutures. On the third evening she had been at-
July 4, 1885.|
PROCEh.DINOS OF SOCIETIES.
23
tacked with severe frontal headache and chills, followed by fever, with
great tenderness over the region of the uterus. There being no im-
provement in her condition, her medical attendant was discharged, and
another called in, who gave such an unfavorable prognosis that he also
was requested to cease his attendance. The patient had well-marked
symptoms of septic poisoning. The pulse ranged from 130 to 140,
was small and thready, and disappeared under the pressure of the
finger; the temperature was 104° to 105°. She was slightly delirious,
and had constant vomiting; the abdomen was swollen and excessively
tender ; the uterus was enlarged, extending fully three inches above the
pubes. In the right side there seemed to be a growth extending up
into the abdomen, tender on pressure. On making a vaginal examina-
tion, the os was found dilated so that the index-finger could readily enter
the uterus. Its withdrawal was followed by a gush of highly offensive
matter. The uterus was surrounded by organized lymph, and was im-
movable. The mass on the right side was easily detected, and was
continuous with the lymph surrounding the uterus. The vagina was
hot. The perinaeum was torn to the anus ; the surface was raw and
discharged an acrid matter which scalded the surrounding parts. The
urine was dark, .and, on standing, deposited a reddish material which
looked like blood-corpuscles. Dr. A. E. Russell examined the specimen
and reported it to be slightly acid, with no albumin or sugar ; under the
microscope occasional pus-corpuscles were seen, and it was swarming
with bacteria. In conjunction with internal treatment, intra-uterine
injections were made three or four times a day. A solution of bi-
chloride of mercury, 1 to 2,000, was first used. This was continued
for three days without any marked results. The discharges continued
as offensive as before. On the fourth day the bichloride was replaced
by a l-to-4,000 solution of biniodide of mercury. Within twenty-four
hours an amelioration of all symptoms took place, the pulse fell to 100,
and the temperature to 101° ; the urine became clear and the discharge
odorless. The injections were continued for ten days, their frequency
being gradually reduced. The uterus returned to almost its normal size,
and the lymph was gradually absorbed. The patient recovered.
Case II. — March 19, 1885, he was called to attend Mrs. W. in her
first confinement. On his arrival, he found she had been in labor sev-
eral hours. Examination showed the os perfectly dilated and the bag
of waters protruding. The presentation was of the vertex, in the first
position, and he ruptured the amnion. The vagina near its outlet was
roughened with venereal warts, and they spread also over the vulva.
Labor progressed rapidly and the second stage was happily ended.
After waiting nearly an hour, making pressure on the uterus, he made
slight traction on the cord, and, while doing so, felt, with his hand
upon the uterus, a cup-like depression of the fundus take place. This
convinced him that he had an adherent placenta to deal with, and that
it would be folly to wait any longer. On introducing the hand he
found the placenta completely adherent, so that it could hardly be said
which was uterus and which placenta. After considerable trouble, he
at last succeeded in detaching the piacenta ; it took fully three quarters
of an hour. On making a second examination, to ascertain if the whole
had been removed, his hand came in content with long shreds hanging
from all sides of the uterus ; the more he scraped, the more there
seemed to be. He gave the patient two drachms of fluid extract of
ergot. She did well for two days, when toward evening she complained
of a chill and severe frontal headache. He then gave her ten grains of
sulphate of quinine, with a quarter of a grain of sulphate of morphine,
at one dose, and washed out the uterus with a l-to-4,000 solution of
biniodide of mercury. The pulse was 115 and the temperature 102°.
The discharge was highly offensive. The injections were repeated every
four hours. On the evening of the next day the pulse was 98, the
temperature 100°, the discharge odorless, and the patient was perfectly
well in ten days more.
Case III. — April 23, 1885, he was requested to call at once to see
Mrs. K., who was reported in imminent danger of death. This was her
ninth confinement. The history of the previous ones, with one excep-
tion, was not good. Her labors had been natural, but followed by ter-
rible flooding and protracted convalescence. He found her in an attack
of puerperal convulsions. He gave at once thirty grains of bromide
of potassium and twenty of chloral hydrate. This dose was re-
peated in half an hour ; ten minutes later another convulsion occurred.
He then bled the patient freely. The os uteri was somewhat enlarged,
the cervix soft and dilatable ; there was a vertex presentation. Dr.
Curtin, whom he had sent for, having confirmed his opinion, and con-
sidering that the patient's time was quite up, it was decided to etherize
her, dilate the cervix, and deliver. The forceps was applied, and trac-
tion made at intervals. A living child was safely extracted. Continu-
ous pressure was maintained over the uterus, but, after the expulsion of
the placenta, the organ did not contract until it had been washed out
with hot water. The bromide and chloral were continued every two
hours, and no more convulsions occurred. The patient did well up to
the fourth day, when the discharges became very offensive and the
pulse accelerated, and slight tenderness existed over the uterus ; but
there was no chill or fever. The uterus was thoroughly washed out
with a solution of biniodide of mercury, 1 to 4,000, and within twenty-
four hours the discharge had become odorless and the tenderness over
the uterus had disappeared. The patient recovered after a tedious con-
valescence.
In these cases it would be seen that the biniodide was
prompt in its action, markedly so in Case I, where the bichlo-
ride and the biniodide were both employed, the result being
decidedly in favor of the biniodide. Naturally, it would be
said, here were only three cases from which deductions were to
be drawn, and it was only after it had been carefully used in a
large number of cases that its efficacy could be proved. It was
for this reason that he brought it to the attention of the mem-
bers of this society, who were in a position to give it a fair and
impartial trial, and at some future time give the results of their
investigations. He bad found the l-to-4,000 solution of the bin-
iodide non-irritating, and had used it extensively in his gynas-
cological practice and in washing out pus cavities with good re-
sults. In it we had a preparation in which the smallest amount
of drug was used with results far exceeding those of any other
antiseptic. On account of the small quantity of mercury, there
would be less chance of salivation. The method he had pursued
in makiDg the solution was : Take three grains and a half of the
salt, well triturated in a mortar and rubbed, with one quart of
boiling water, slowly added, giving a solution of 1 to 4,390.
Since writing the foregoing he had seen in the " Philadelphia
Medical Times" for May 16th that Dr. Panas, eye surgeon of
the Hotel-Dieu, used the l-to-25,000 solution of biniodide of
mercury in eye cases. He made the following statements:
" After a number of experiments, I have convinced myself that
a solution in water, 1 to 10,000, of the bichloride, or a similar
solution, 1 to 25,000, of the biniodide of mercury, is much supe-
rior to any other antiseptic solution employed in eye surgery.'
Here again we had a statement that the biniodide in a smaller
quantity was as good an antiseptic as the bichloride.
Dr. Montgomery's experience had led him to the conclusion
that the bichloride of mercury was far more effective as a disin-
fectant than carbolic acid. Its introduction into the Philadel-
phia Hospital had been due to Dr. Parvin, who had found it
very satisfactory. In eighteen cases of puerperal fever that were
treated with bichloride injections, only three deaths occurred.
This success was attributed by the hospital staff to the use of
the bichloride. In private practice the speaker followed the
plan of Dr. Garrigues, of New York, and avoided intra-uterine
injections after labor, but applied pledgets wet with a bichloride
solution over the vulva, after carefully cleansing away clots and
washing the external parts with a similar solution. In his last,
term at the Philadelphia Hospital he had bad only two eases of
puerperal fever, one of which commenced twelve days after de-
livery. The history of Dr. Bernardy's cases showed an equal if
not better antiseptic power in the biniodide of mercury.
Dr. J. V. Kelly some years ago had had several fatal cases
of puerperal fever, and about twenty-five patients that got well.
24
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jor k.,
The trouble commenced in a case of abortion, in which he did
not succeed in removing all of the placenta. He was at the same
time attending a bad case of erysipelas, and at that time the
relationship of puerperal fever and erysipelas was not known to
bim. He was on the point of giving up his practice and leaving
the town, and he consulted Dr. Goodell on that question. Dr.
Goodell discountenanced such action, but advised him, when
attending an obstetric case, to remove bis coat and roll up his
sleeves, and wash his hands and arms well with turpentine, using
the nail-brush thoroughly. Since that time he had washed his
hands in turpentine every day and again before every case of
labor. He also used a wash of vinegar or carbolic acid solution
before touching a puerperal patient. He had met with no puer-
peral fever or other septicemic symptoms since that time.
Dr. Parvin said that, as reference had been made to his
having used corrosive-sublimate vaginal injections in the cases
of puerperal septicaemia under his care in the Philadelphia Hos-
pital last year, he would refer to the antiseptic treatment in the
cases occurring the present year. When he took charge of the
obstetrical ward, on the 1st of January, he found five recent
cases of septicaemia: two of these patients died; one of the two
had apparently recovered and then was attacked by pneumonia
— quite possibly this pneumonia had a septic origin. Then
there were at least seven other cases, but all these patients, as
well as three of the original five, recovered. Injections of a
solution of corrosive sublimate, 1 to 5,000, were used in all
cases immediately after labor. The external parts were washed,
too, with a similar solution. This injection was repeated twice
a day in all cases for the first week after labor, while it was used
oftener in those having septicaemia. Intra-uterine injections were
used only when vaginal injections failed to correct the offensive-
ness of the discharge, but, as was well known, there might be
serious, even tatal, cases of septic disease though the lochial How
was not at all offensive. In private practice, after once wash-
ing out the vagina thoroughly with the antiseptic solution im-
mediately after labor, this need not be repeated unless symp-
toms demanded it, but the bathing of the vulva twice a day
with the solution ought not to be omitted. Add, if preferred,
to this treatment the use of antiseptic napkins, a practice pur-
sued by Dr. Montgomery at the Philadelphia Hospital so suc-
cessfully, and he thought we had taken the most important
means to guard against the entrance of septic germs after labor.
He had had no experience with the biniodide of mercury, and
did not know that it would supersede the bichloride. The ar-
gument in its favor was as strong as three successful cases
could make it, but these were entirely too few, as Dr. Bernardy
had justly said, to prove its value and its superiority. In one
of the doctor's cases labor was induced, apparently on account
of eclampsia. Now, was this the best treatment? Obste-
tricians were by no means agreed, some of the best condemning
such treatment.
Dr. Montgomery used the bichloride solution as an externa]
wash only, not as an injection. He thought the records of the
hospitals in which injections were used would not show such
good results as those in which they were omitted, if septicaemia
was not present.
Dr. Wh.lard had a warning to sound with regard to the use
of strong bichloride solutions. He had been using washes and
antiseptic dressings made with a l-to-1,000 solution of bichlo-
ride, but, in consequence of what had been written about the
advantages of stronger solutions, he had increased the strength
to 1 to 500, and within twenty-four hours the stools contained
bloody mucus, and were small and griping; there was vesica-
tion about the wound and around the limb under the dressings.
Entirely dry dressings had been used, but they had been moist-
ened by pus and serum from the wound. He did not see the
advantage of solutions in serum so strong as 1 to 100 or 75.
Serum was a decomposable substance, and an uncertain portion
of the antiseptic agent was destroyed by it. Weak solutions in
boiling water seemed more reasonable, and answered every pur-
pose.
Dr. Longaker would like to hear how Dr. Bernardy re-
moved the placenta in the case of adhesion narrated by him.
He had been using Crede's method with great satisfaction, lb-
thought the hand should be kept out of the parturient canal as
much as possible. He did not use vaginal injections after labor,
but depended upon outside washes. He found that the tem-
perature rarely rose during the puerperal period, even after in-
strumental delivery. He thought care during the third stage
would avoid the necessity for antiseptics.
Dr. Parish agreed with Dr. Parvin's views. He had found
a solution of 1 to 1,000 of bichloride irritating, and he now used
one of 1 to 2,000 or 5,000. Strong solutions caused an appear-
ance resembling erysipelas or inflammation of the derma. In-
jections were not necessary in every case. Where the surround-
ings were cleanly and the patient was a multipara he did not
use them ; but in primiparas, with contusions or lacerations, and
when version or instruments had been employed, he was in the
habit of injecting a weak solution of bichloride immediately
after delivery. He did not repeat it, but simply washed out the
vagina. Cleanliness of hands, instruments, and nurse was the
most important point. He had never had any trouble in private
practice.
Dr. Bernardy, in closing the discussion, remarked that he
thought he had a far better antiseptic in biniodide than the bi-
chloride. He had used the former in surgical cases also, for
washing out pus cavities, and always with good results. He did
not use intra-uterine washes in every case of labor. He had at-
tended, since the first of the year, about seventy cases of labor,
and he had employed the intra-uterine injections in only the
three cases detailed. In every case of labor he used carbolic-
acid soap on his hands and arms and the external genitalia of
the patient. The eclamptic patient had reached or passed ber
full term, and there was no reason why the child should not be
removed. In the case of adherent placenta it was peeled off for-
cibly and a shreddy lining was left in the uterus, as no line of
separation had formed. He believed the dangers consequent on
passing the hand and arm into the uterus and vagina were much
exaggerated, and he did not hesitate to do so when the exi-
gencies of the case demanded it.
(7b be concluded.)
NEW YORK OBSTETRICAL SOCIETY.
Meeting of January 20, 1885.
Dr. W. M. Chamberlain Chairman pro tern.
A Spiral Tenaculum was presented by Dr. James B. Hun-
ter, who had found it especially useful in operations for fistulas
within the vagina and for repairing the perinseum and cervix
uteri. The instrument retained its grasp upon the tissues more
firmly than the ordinary tenaculum, and was easily engaged and
disengaged.
A Soft-Rubber Female Catheter was also presented by
Dr. Hunter. The opening was at the extremity of the tube,
and the walls gradually increased in thickness toward one end.
He had known nurses to set up a urethritis or cystitis by the
use of rigid catheters after minor operations, which was more
troublesome than the original disease. He never employed the
silver catheter, because of the danger of the mucous membrane
becoming engaged in the orifice and being injured.
The Chairman thought the spiral tenaculum might enable
July 4, 1885.J
PROCEEDINGS OF SOCIETIES.
25
us to avoid hacking the tissues, which sometimes took place
when the ordinary tenaculum failed to retain its grasp. With
regard to the rubber catheter, he asked if it would not in some
cases be too soft.
Dr. Hunter said that when a firmer instrument was required
the ordinary rubber male catheter could be used.
Removal of the Ovaries and Tubes for Extreme Dys-
menorrhcea and Mania.— Dr. B. F. Dawson presented the
Fallopian tubes and ovaries removed two days before from a
patient with the following history : She was thirty-six years of
age, from New Jersey, had been suffering from apparently hys-
terical symptoms for two years, and from dysmenorrhoea, which
became more aggravated at each return of the menstrual flow.
Dr. Dawson first saw her eighteen months ago, but was unable
to make a satisfactory examination of the pelvic organs because
of hyperaasthesia and symptoms of hysteria. Two months after-
ward he made another examination, and found tenderness over
the region of both ovaries, but the patient's condition was still
such as to forbid a thorough exploration of the pelvic organs.
She then passed into the hands of a physician prominent in the
treatment of nervous diseases, who stated that her symptoms
were due 'to simple hysteria and nervous disturbance. But she
grew worse, and became the subject of marked convulsive seiz-
ures, and two months ago was advised to come to New York for
further examination and treatment for disease of the sexual
organs. December 29th her physician, Dr. Allen, wrote Dr.
Dawson that she was in one of her periodical attacks, and had
for four days been lying in a maniacal state. He advised that
an operation be performed for her relief before the return of
another menstrual period, as it was feared she would not be able
to live through another attack. The patient arrived in New
York on Saturday night, pulseless at the wrist, the extremities
cold, the mind lethargic. There was ovarian enlargement with
tenderness. After a consultation it was decided to operate the
next morning, but, when morning came, two hours were spent in
stimulating the patient, to put her in a condition at all suitable
for an operation. It was probable that not more than a wine-
glassful of blood was lost during the operation. The right ovary
was removed with some difficulty. The left one was as large as
a hen's egg, and bound down by adhesions. While he was
endeavoring to liberate it it burst in his hand, and material
escaped which felt like lumps of charcoal. It proved to be a
black, granular mass, probably composed of coagulated blood
which had become encysted within the tumor. This ovary also
contained several cysts, and both organs were in a state of con-
gestion. The patient rallied well just after the operation, her
mind was clear, and she said she felt better than for many
months, and confidently believed that she would recover. But
the following morning the temperature rose to 105-5° F., and,
although it was readily reduced temporarily by the coiled tube
conveying water, it would again rise, and death seemed inevita-
ble. At 4 p. m. the pulse could scarcely be felt at the wrist. By
request, Dr. Howe transfused about three ounces of blood and
an equal quantity of salt and water. But neither the pulse nor
the respiration showed any marked improvement, and she died
in the morning. Death might have been accelerated by shock,
but it was thought to be chiefly due to inanition and loss of
nerve power resulting from protracted illness.
Dr. Dawson was of opinion that the blood-clot removed
from the left ovary was formed at the last menstrual period,
when it was feared that the patient would die. He attributed
her symptoms to the condition of the ovaries, and said that, had
an operation been allowed when he urged it six months ago, the
patient would have stood a better chance of recovery, and would
have been spared months of extreme suffering.
Dr. A. Jaoobi said that, in order to complete the history of
the case, one or two things would be desirable. One was, recov-
ery after the operation ; another, since the patient had died, a
post-mortem examination, and he would suggest that, if it was
possible, one should yet be made. Those who had listened to
the history had not seen the patient; certainly Dr. Dawson had,
and he had given reasons why he had regarded the symptoms as
of reflex origin, and therefore had operated upon the ovaries.
But possibly an autopsy would give a clew to the origin of the
symptoms, as it had done in some other cases, in a direction dif-
ferent from that to which Dr. Dawson had pointed. He would
not say that this was one of the cases, but meningitis, more or
less localized and more or less old, had given rise to a great
many symptoms which had very frequently been mistaken for
reflex symptoms. He therefore thought that a post-mortem
examination would be very important in order to determine
absolutely that there was nothing in the brain which might
explain the symptoms. If nothing was found in the brain he
would certainly be of the same opinion with Dr. Dawson, that
the ovaries were the cause of all the symptoms complained of
for so many years.
Dr. Dawson remarked that the maniacal symptoms dated
back only a few menstrual periods, and that after the operation
the patient became clear in her mind. The history was not one
of meningeal trouble.
Dr. Jacobi said there were many cases of meningitis which
did not show pathognomonic symptoms. He did not think our
knowledge of reflex symptoms was sufficiently advanced to en-
able us always to exclude disease of the central organ of which
we knew so little.
Dr. Dawson said that a year ago, at the request of Dr. C.
H. Brown, he saw a woman with mania, in whom he detected
an enlarged ovary, and, inasmuch as there was a possibility of
the mental trouble being of reflex origin, he advised an opera-
tion, which was consented to. The specimen was shown to the
society. He saw the woman about six weeks ago, and her hus-
band told him that she was herself again, and absolutely free
from maniacal symptoms ; the operation, he said, had cured her.
A month ago, however, her symptoms of mania had returned.
This case would go to support the view taken by Dr. Jacobi
that we were in ignorance of the influence which disease of the
ovaries might have in the production of mania.
Dr. Hunter thought that time enough was not always al-
lowed to elapse after removal of the ovaries before denying its
beneficial effect. He recalled a case operated upon by Dr.
Thomas some years ago for the relief of maniacal symptoms for
which the patient had been restrained nearly a year. Both
ovaries were found to be diseased, but no improvement fol-
lowed their removal ; the patient became a hopeless maniac.
But, after the lapse of a number of months, improvement began,
and now, two years after the operation, the patient was perfect-
ly well. She had been a burden to her household for ten years.
Dr. Hunter had seen several other cases in which recovery did
not begin to take place for from twelve to eighteen months after
removal of the ovaries for symptoms attributed to disease of
those organs.
Dr. Jaoobi inquired of Dr. Hunter whether he attributed
the patient's improvement eighteen months after the operation
to removal of the ovaries.
Dr. Hunter replied that that was the deduction ; there was
no question as to disease of the ovaries ; they were both cystic.
The symptoms of mania began with dysmenorrhea, and were
aggravated during each menstrual period.
Dr. Jaoobi thought that such cases ought to be accepted
with a good deal of doubt. Eighteen months was a long time
to wait after an operation for recovery to take place ; he did
not think that so great a length of time should be required for
26
MISCELLANY.
[N. Y. Med. Joub.,
the absorption of inflammatory deposits which might have oc-
curred in the neighborhood of the diseased organs and caused a
continuance of the symptoms. Besides, there were many cases
of mania which got well without removal of the ovaries, and
cases of the kind related by Dr. Hunter should not, therefore,
be allowed to prove too much in favor of the operation.
Dr. Hunter remarked that in the case to which he referred
menstruation had continued with more or less regularity a year
or two after the operation. He had records of cases in which
menstruation had continued for about a year after the opera-
tion. If the periods continued to recur for a year, it was not
unreasonable to suppose that improvement would begin at the
end of that time. He believed, with Dr. Jacobi, that it would
require a number of cases to prove the matter positively.
The Chairman inquired whether we were to understand that
the improvement began with the cessation of menstruation.
Dr. Hunter replied in the affirmative. He further referred
to a case of which he had very full records — that of a woman
who had suffered from dysmenorrhcea of increasing severity for
eight years. She preferred death to her condition before the
operation. No marked improvement followed the removal of
the ovaries, and at the end of six months she was still suffering
from severe pain. At the close of the year, however, she wrote
that she was perfectly well. She menstruated about the elev-
enth month after the operation. One ovary had been found to
be enlarged and cystic, and both tubes were enlarged.
Prolapsus of the Rectum— Dr. A. Jacobi related the his
tory of a case of prolapsus of the rectum in a child nearly three
years of age, which was presented at his clinic recently. As it
entered the room it walked a little peculiarly, as if suffering
from soreness of the inguinal glands. It was unable to have a
movement from the bowels without straining, and in the pas-
sage of both fasces and urine was obliged to lie upon the belly
and face. Dr. Jacobi attempted to place the boy upon a chair,
but he struggled against it, and his mother said he was unable
to sit. On letting his pantaloons down it was observed there
was prolapsus of the rectum a distance of three inches, present-
ing the appearance of a sausage of a dark- red hue. The protru-
sion bled very easily when touched. At the outer end was an
opening, into which he inserted his thermometer-case to take
the measurements. As the silver case passed the anus it was
grasped rather tightly, which would explain why there had
been difficulty in having passages. This condition had lasted
for three weeks. An attempt had been made at reduction, but
unsuccessfully. Dr. Jacobi supposed the intestine, being so
tightly grasped by the anus, could not be in a healthy condi-
tion, and, on examining the parts with great care, he found that
at the seat of the constriction there were numerous cuts, with
rough edges, of varying depth, some extending as deep as the
peritoneal coat, showing that amputation of the protruded gut
was gradually taking place. He certainly would not undertake
reposition at the college clinic-room, and, accordingly, had the
child sent to Mount Sinai Hospital, there to be kept under ob-
servation. It seemed wiser to allow the colon to become gradu-
ally amputated than to undertake reduction, in view of the lia-
bility of tearing the exposed peritonasum. He drove to the
hospital himself shortly after the child was sent, to instruct the
house physician to do nothing in the case except under his
directions or those of the physician in charge. He was told the
next day that one of the assistants, on seeing a case of prolapsus
of the rectum enter the wards, availed himself of the absence of
the house physician, and squeezed and handled the parts long
enough to reduce the protrusion. The next day the child had
some difficulty in passing fasces, but the difficulty disappeared
by the third day. Little or nothing that was peculiar could
be felt in the rectum ; probably the incarcerated parts were
too high to be reached. But the patient was unable to pass
urine, and the catheter had to be used. Six or seven days
afterward, learning that the elastic catheter had been used two
or three times daily by the nurse in the presence of the house
physician, Dr. Jacobi told the physician to employ a silver
catheter so that the bladder could be properly explored. A
good deal of difficulty was experienced in introducing the cathe-
ter ; the bladder was bent at its neck, and some force had to be
employed to overcome the obstruction. Before the catheter was
withdrawn the curve was turned, which straightened the canal,
and no further difficulty was experienced in urination. It was
not easy to say what had caused the flexion of the neck of the
bladder to become aggravated on the reduction of the prolapsed
rectum. It could not very well have been caused by peritonitic
adhesions, for the reason that one introduction of the silver
catheter, with anteflexion of the bladder to the normal or nearly
normal position, was sufficient to relieve the trouble. While
the child at present seemed to be quite well, an important ques-
tion arose as to what would be the final result in the case. It
was hardly possible that a considerable amount of cicatrization
would not take place where there had been partial amputation
of the gut, and it seemed more than probable that in the course
of time the child would suffer from stricture of the intestine. If
this should occur, the case would be a difficult one to treat,
because of the marked sigmoid flexure which existed in chil-
dren. Had spontaneous amputation taken place the child would
have been under his immediate observation, and it was not
probable that it would have been attended by any serious danger,
inasmuch as a portion of the gut was sometimes successfully
amputated in intussusception.
The Chairman thought there was at present danger of faecal
matter becoming lodged in some of the cuts within the intes-
tinal coats, and producing further injury.
Henry J. Garrigues, M. D.,
B. F. Dawson, M. D.,
Frank P. Foster, M. D., ex officio,
Committee on Publication.
The Albany Alumni Lectures. — The " Albany Medical Annals " an-
nounces that the next course will be given on the 3d of March, 1886,
by Professor S. Oakley Van der Poel, M. D., LL. D., of New York, on
" Hygiene ; its Relations to the Profession and the General Public."
The Republic of Guatemala owes a debt of gratitude to a physician
of this city, who, according to the " Eastern Medical Journal," has pre-
sented a collection of serpents to the American Museum of Natural
History which consists of " all the serpents of the Republic of Guate-
mala." Surely an easier way of ridding a country of snakes can
scarcely be imagined, although our contemporary does not give us the
modus operandi by which it was accomplished.
Infectious Endocarditis. — We are indebted to Dr. John H. Musser
and Dr. George A. Piersol, of Philadelphia, for a copy of their pam-
phlet entitled " Notes of a Case of Infectious, so-called Ulcerative, En-
docarditis, and of a Case of Acute Pericarditis," extracted from the
" Transactions of the College of Physicians of Philadelphia." It has
seldom been our fortune to meet with so satisfactory a clinical study,
and we would particularly commend the photographs, by Dr. Piersol,
which accompanied the copy sent us. They seem to represent the per-
fection of the photographic art as applied to medicine.
The French Medical Year-Book. — We have received from the pub-
lishers, the Messrs. E. Plon, Nourrit et Cie., of Paris, the seventh vol-
ume of the " Annee medicale," for the year 1884. This excellent pub-
July 4, 1885.]
lication, edited by Dr. Bourneville, the redacteur en chef of the " Progres
medical," with the collaboration of a number of eminent practitioners,
furnishes a resume of the progress of medicine during the year. It
is divided into departments corresponding to the practical branches, and
an excellent index makes it easy of reference.
Parturition and Measles. — Dr. A. R. Simmons, of Ithaca, N. Y.,
writes as follows: "On the morning of March 22d I first saw the pa-
tient. On Friday morning, the 20th, she had complained of headache
and sore throat, and the next day she had begun to cough. That night
labor pains set in and continued all night. The next morning I found
the mouth of the womb patulous, but the pains had nearly ceased. The
conjunctivae, the roof of the mouth, and the throat were then reddened,
and she coughed a little. Labor pains began again about 6 p. m., and
the child was born about 1.30 a. m. It was a normal labor in every re-
spect, and the signs of measles were then very prominent. Seven
hours afterward the measles rash was out on her face and neck, there
was some delirium, the pulse was 128, and the temperature was 104° F.
I was obliged to catheterize her, and continued to do so until April 3d ;
the expulsive power and the desire to urinate were wanting. The aver-
age daily quantity of urine was about a pint, and it contained no albu-
min or casts. On the 24th the pulse was 108, and the temperature
100°; the tongue was moist. She had passed a very good night, but
with some delirium. The rash covered the whole body ; the cough was
severe, the result of the usual bronchitis ; there was some soreness over
the bowels, but pressure was very well borne ; the lochia were normal ;
the bowels had moved. At night the pulse was 100, and the tempera-
ture 101-3°; there was no tympanites. On the 27th the temperature
was 100'8°, and the pulse 120; there was no tenderness of the abdo-
men, but her back ached ; the lochia were offensive, but normal in
quantity ; the breasts were full of milk. In the afternoon the tempera-
ture was 99°, and the pulse 100 ; a free movement of the bowels had
been secured, which had relieved her. From this time she convalesced
rapidly, and was sitting up on the sixteenth day after delivery.
"I consider that there was no possibility of error vin the diagnosis of
measles ; a very extensive epidemic was raging at the time, and a case
had occurred in the same house early in the month. Knowing that the
pregnant woman had not had measles, I advised her removal from the
house, but it was not done. The baby coughed some on the 29th and
30th of March, and a rash appeared on the latter day, but, when I saw
it at night, it was hardly perceptible, and it was all gone the next day.
The child had a convulsion on the 2d of April, but, has since been well.
I will add that in the same epidemic a child seven weeks old had the
measles a week after its mother was attacked. Both recovered."
Congenital Dislocation of the Patella. — A correspondent writes
from Louisville, inclosing a letter from a former pupil of his, asking for
information bearing upon the following case : A girl, seven years old,
having loose joints, although in robust health, has the patella resting
on the external condyle. It is easily replaced while the limb is ex-
tended, but requires considerable force to keep it in place during flex-
ion. Both limbs are affected alike. The girl's father, her aunt, and
the aunt's daughter, all have their patellas resting on the outer condyle.
The doctor asks : Can anything be done to rectify the deformity, what
can be done, and is there anything in literature in regard to such an
hereditary deformity ?
Prevailing Diseases in Illinois. — A correspondent writing from
Stillwell, 111., says that he has encountered an " epidemic " of inflam-
matory rheumatism and one of paralysis in both children and adults ;
also that he has regularly to contend with typho-malarial fever in the
autumn and cholera infantum in the summer. He would be glad to
receive hints as to the management of these various affections.
A Correction. — We regret that an error crept into our report of the
proceedings of the recent annual meeting of the Illinois State Medical
Society. In the issue for June 20th, page 701, we gave an abstract of
a paper entitled '' How the Vitality of a Seed is Preserved," and credited
the paper to Dr. H. Judd, of Galesburg. The paper, we now learn, was
really read by Dr. A. Wetmore, of Waterloo, and we take pleasure in
making the correction.
27
THERAPEUTICAL NOTES.
Veratrum Viride in the Treatment of Palpitation. — M. See (" Union
med." ; " Dtsch. Med.-Ztg.") recommends the use of tincture of vera-
trum viride for controlling over-action of the heart in cases of exoph-
thalmic goitre. From three to five drops are to be given three or four
times a day, for several weeks or months together.
Persian Insect Powder as a Medicine. — The "Deutsche Medizinal-
Zeitung" alludes to the fact that a Russian physician, Dr. Swiontezki
has lately recommended an alcoholic extract of Persian insect powder,
with the addition of santonin, as a " sure cure " for cholera ; and then
quotes from another Russian source to the effect that enemas of the
insect powder are effective in the treatment of ascarides, and have no
poisonous action.
Massage in the Treatment of Faecal Accumulation. — Kriwjiikin
(" Protok. der kankasisch. med. Gesellsch." ; " Dtsch. Med.-Ztg.") re-
ports four cases of obstinate constipation, varying from eight to twelve
days in duration, in which the trouble was overcome by deep massage.
The fingers, previously oiled, are to be pressed firmly upon the abdo-
men, and movements of massage are then to be executed, especially
upon those parts where hardened masses are felt. The process is to be
continued for twenty minutes, and repeated at intervals of an hour and
a half until the bowels are moved.
Strychnine in the Treatment of Supra-orbital Neuralgia. — Howe
("Revist. Argent, de Buenos Aires" ; "Dtsch. Med.-Ztg.") has succeed-
ed in curing with strychnine a patient who had suffered for fifteen
years with a neuralgia that had resisted all other treatment. Four hy-
podermic injections of the drug were given at the seat of the pain, and
this was followed by improvement. The subsequent injections were
thrown into the back. The treatment lasted three weeks, and the result
is said to have been brilliant.
Sucupira. — This seems to be the generic name of the soukoupire, a
tall tree found in several varieties in Brazil. According to M. Cam-
pardon ("Gaz. hebdom. de med. et de chir."), the Brazilians use the
bark as a depurative and to mitigate the pain of rheumatism.
Iodine and Pyridine in the Treatment of Asthma. — The alkaloid
termed pyridine (C5H6N) is a colorless, volatile liquid, of a very pene-
trating odor, miseible with water, and forming with the mineral acids
salts which are very soluble but unstable. It is obtained by the dry
distillation of various organic substances, such as Dippel's animal oil,
certain alkaloids (including cinchonine, quinine, morphine, and atropine),
and coal-tar. It is found also in the condensed products of tobacco-
smoke and in nicotin itself. M. Germain See lately read an interesting
paper before the Academie des sciences (" Rev. med.") on the use of py-
ridine in the treatment of asthma. He declares that iodine is the great-
est curative agent in this affection, whatever form it may take, and that
pyridine is the best palliative for use during the attacks. It causes a
decided and immediate diminution of the feeling of oppression, so that
the breathing becomes calm, while the action of the heart preserves its
regularity as well as its force. After about an hour there is in many
cases an irresistible desire to go to sleep, but no stupor or any approach
to anaesthesia, although the reflex excitability is diminished. The rem-
edy should be given by inhalation, a fluidrachm or more being poured
on to a napkin in a close room. The inhalation should be continued
for twenty or thirty minutes, and should be repeated three times a day.
After two or three inhalations, auscultation will show great improve-
ment of the physical signs. A few persons seem to have their suscep-
tibility to the action of the drug impaired at the end of a week or ten
days, and then it is well to begin with the iodine treatment.
Preparations of Iodoform. — The same journal quotes from the
"Courrier medical" as follows:
Iodoform 15 grains ;
Glycerin 5 drachms ;
Essence of mint 6 drops.
Used on vaginal tampons.
Iodoform 15 grains;
Glycerin 75 "
Distilled water 3 ounces.
For injections in cases of gonorrhoea and chronic catarrh of the
bladder.
MISOELLAN ¥.
28
MISCELLANY.
[N. Y. Mbd. Jock.
Iodoform 15 grains;
Sulphuric ether, 1^ 75 „
Olive oil, )
For subcutaneous injections in cases of syphilis, from half to three
quarters of the mixture being used daily or every other day.
Iodoform 15-30 grains;
Potassium iodide 1 drachm ;
Tokay wine 2£ drachms.
For internal use, in cases of convulsions, in doses of from three to
fifteen drops, in a glass of wine, three times a day.
Iodoform H grain;
Lyeopodium 6 grains ;
Extract of phellandrium seed 15 "
Divide into ten pills, from three to five of which are to be taken
daily, for bronchorrhoea or emphysema. It should be borne in mind
that the internal use of iodoform disposes to haemoptysis.
Discs for Sick Headache. — At a recent meeting of the Societe de
therapeutique (" Progr. med.") M. Mayet, his, stated that he had had
discs made after the following formula :
Menthol, )
Chloral hydrate, f each 7* grains ;
Spermaceti 30 "
Cocoa butter 15 "
A disc is to be bound on over the seat of the pain. M. Mayet said
that he had never observed that these discs had an irritating effect.
Erythrina Corrallodendron as a Calmative. — Bochefontaine and
Rey (" Annee med.") have found this plant, which is in common use in
Brazil, where it is called mulangu or murungu, of service as a calma-
tive and hypnotic in the agitation and sleeplessness of the insane, seven
or eight grains of an extract being sufficient to cause sleep in such
cases.
The Treatment of an Acute Attack of Articular Gout. — In a re-
cent monograph by Dr. Robson Roose (London : H. K. Lewis), the
author says that, when called to a case of this sort, he invariably exam-
ines the urine for albumin. If he finds none, and there is constipation
with signs of congestion of the liver, he orders two or three grains of
calomel, to be followed by a draught containing sulphate and carbonate
of magnesium. If there is no marked evidence of hepatic congestion,
milder remedies will suffice for the constipation ; the saline draught
alone, or ten grains of pilula colocynthidis et hyoseyami, with perhaps
a grain of calomel or a quarter of a grain of resin of podophyllum, gen-
erally producing a free action of the bowels. At the same time he
orders a mixture containing ten minims of wine of colchicum and from
ten to twenty grains of some alkaline salt, such as bicarbonate of potas-
sium or of sodium, carbonate of magnesium, or citrate of magnesium or
potassium. This should be taken four times in the twenty-four hours,
and continued according to circumstances. If there is much fever, two
drachms of solution of acetate of ammonium may be added to each
dose. The following application gives great relief from the pain :
Extract of belladonna 2 drachms ;
Glycerin | ounce ;
Water 2 drachms.
It is applied to the affected joint on cotton wool, and the part
should be raised on a pillow and kept in a comfortable position. While
active symptoms continue, the diet should be restricted to such articles
as arrowroot, sago, gruel, milk puddings, etc. Seltzer, Apollinaris, or
any other aerated alkaline water may be used freely. When the acute
symptoms have subsided, beef-tea, fish, and chicken may be taken in
small quantities, but the return to the usual diet should be very gradual.
Rest and care are essential for some days after the subsidence of the
paroxysm. Leeches, blisters, and especially cold applications, should
be avoided.
The Hygiene of the Lying-in Chamber. — In a recent address before
the Medical Society of the County of Albany (" Albany Med. Annals "),
Dr. T. K. Perry said : " I attend everything that I am called to within
the legitimate domain of my profession, from scarlet fever to phage-
denic erysipelas. I witness, assist in holding, and hold a fair number
of autopsies every year, and all this time keeping right on with my ob-
stetric work without regard. I have never ordered the paper from the
walls of the expected lying-in chamber, nor have I ever had them sized
with a solution of mercuric bichloride. Neither do I immerse hands or
instruments in any disinfectant previous to or during attendance on
these cases. I will also add that I have never in a single instance em-
ployed intra-uterine injections at such times, contenting myself with
simple vaginal douches ; and, notwithstanding this very great careless-
ness and almost criminal neglect on my part, I am still able to hold up
my hands for inspection, and find them perfectly clean, washed of even
the stigma of misfortune. Not a death has occurred to any patient I
ever attended during confinement, save as above reported [two deaths
from haemorrhage and one from eclampsia] ; and, although I have
many times witnessed chill, fever, abdominal tenderness, etc., hot water
per vaginam, hot fomentations to the abdomen, diet, and anodynes have
constituted and completed the treatment and cure."
Inhalations of Oxygen for Puerperal Convulsions. — It is known,
says Holstein ("Gaz. med. de Paris") that oxygen has the property of
enfeebling, or, to use a fashionable term, "inhibiting," exaggerated
reflexes. On the strength of this fact, Professor Lachkievitch, of
Kharkow, lately proposed inhalations of oxygen in cases of puerperal
eclampsia of reflex origin. In two consecutive cases Favre (" Wratch "),
acting on the suggestion, has produced truly brilliant results. He is
convinced that a bag of oxygen will soon be considered as indispensa-
ble in lying-in hospitals and obstetrical clinics as the forceps, the cranio-
clast, and other like instruments.
Tannate of Mercury in the Treatment of Syphilis. — According to
Leblond ("Gaz. hebdom. de med. et de chir."), this new preparation of
mercury (the hydrargyrum tannicum oxydulatum of the Germans) has
the composition Hg2 (C27Hi90.7)j. The simplest way of preparing it is
by adding to a solution of mercurous nitrate a slight excess of sodium
tannate in solution. The tannate of mercury falls in the form of a
yellow precipitate which rapidly turns green. It is washed by deeanta-
tion until the washings no longer precipitate on the addition of acetate
of lead, and cease to show an acid reaction. The precipitate is then
collected on a filter and dried in the open air. It is insoluble, and
should be given in the form of pills, for which Casanow's formula is as
follows :
Tannate of mercury 45 grains ;
Extract and powder of licorice q. s.
Divide into sixty pills ; two to be taken twice a day, after eating.
The salt is incompatible with alkalies, even in weak solution.
The Action of Veratrine in Cholera Nostras. — Schulz ("Dtsch.
med. Wchnschr." ; " Ctrlbl. f. klin. Med.") infers that the effect of this
alkaloid in the treatment of cholera nostras is not due to its action on
the micro-organisms, but to its inducing a temporary hyperamia of the
intestine, whereby the resisting power of the latter is enhanced.
Lotions for Pruritus of the Genitals. — A contributor to the " Union
medicale " credits Doyon with the following prescriptions :
Bichloride of mercury, ) each 4 .
Chloride of ammonium, )
Almond mixture 13 ounces.
In case this fails, use :
Chloral hydrate 75 grains ;
Rose-water 3 ounces ;
Distilled water 4^ "
After the parts have been bathed with the lotion, they are to be
powdered with starch.
Cocaine in the Treatment of Sore Nipples. — Herrgott (" Ann. de
gynec." ; " Union med.") sums up his experience as follows : 1. All the
women with sore nipples who came under observation were able to give
suck without pain after a four-per-cent. solution of cocaine hydro-
chlorate had been applied to the nipple. 2. The condition of the nip-
ple was improved, and, where the cracks were not deep, they disap-
peared rapidly. 3. Cocaine should be used whenever the nipples are
sensitive, in order to prevent fissures, the latter being often due to a
shrinking movement on the part of the mother whenever the child
seizes the breast.
THE NEW YOEK MEDICAL JOURNAL, July 11, 1885.
Wttt xx res aitir ^irbr esses.
LECTURES ON"
ELECTRICITY IN MEDICINE,
DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI-
VERSITY OF VERMONT, BURLINGTON,
By AMBROSE L. RANNEY, M. D., New York.
Lecture I.
(Continued from page 7 15.)
THE CHOICE OF A BATTERY AND ELECTRICAL APPARATUS.
In selecting a battery for purely medical purposes, the
chief objects to be attained are (1) cheapness ; (2) con-
stancy of the elements, and their accessibility for repairs,
cleaning, etc. ; (3) durability of the elements ; (4) a sufficient
number of elements ; (5) ease of renewal of the elements ; (6)
ease of introduction of any number of elements into the circuit ;
and (7) an ability to select such as may be required from
any part of the battery.
Fig. 26.— The Physician's Handy Cabinet Battery. — The accompanying
cut represents a light and compact form of cabinet battery, designed by the
author. It iH on castors, and can be wheeled about the consultation-room.
This admits of the use of the instrument when the patient is in the gynae-
cological chair or upon the office lounge ; or when any form of fixed appa-
ratus, such as the laryngoscope, the inhaler or spray, etc., is being simul-
taneously employed. In some of my later models an immovable tray is
placed beneath the battery for electrodes, and a movable shelf is also pro-
vided upon which a milliampere-meter, the solution of table salt, and the
electrodes in actual use can be set. A glass cover protects the battery from
dirt when not in use. E, faradaic coils ; K, plunger ; G, faradaic binding-
posts ; F, interrupter ; I), drip-cup ; R, current-selector of single cells ; S,
the same of four cells to each button ; M, coil to work the interrupter for
the galvanic current ; L, switch to work or disconnect the interrupter (V) ;
P, galvanic binding-posts ; 3-5 and 4-ti, connecting rods to allow of the
action of M. The commutator lies above P.
For the general practitioner it is necessary, as a rule,
that a galvanic or faradaic battery shall be arranged for
transportation ; hence the cups which hold the fluid should
have a rubber cover, or some other device which will pre-
clude the possibility of spilling the fluid. Again, some
of the batteries manufactured are liable to become rapidly
oxidized by the fumes of the battery fluid. This tends to
destroy their durability, and to cause difficulty in keeping
them in good working order. Finally, it is very desirable
that portable batteries should be as light as possible, and
not too large to be handled easily.
The attachments upon the key-board of every portable
galvanic battery should comprise a current-selector and a
commutator. There should be at least four rheophores, in
order to make allowance for breakage, additional connec-
tions, etc. Several electrodes of different sizes and shapes
should also be selected — preferably a large, a medium, and
a small one — a wire brush, and an interrupting electrode.
These can be added to as circumstances demand.
For office purposes a cabinet battery has some decided
advantages over a permanent one placed in an adjoining
closet or cellar and connected, by means of wires, with a
key-board in the consulting-room. A cabinet battery can
be easily wheeled about, and is readily repaired. The cabi-
net should be so arranged as to allow the back and front of
the compartment for the cells to be removed, in case the
battery needs repairs, or a renewal of the fluid. The con-
nections of the battery with the key-board should also be
made as easy of access as possible ; this decreases the ex-
pense of alterations or repairs when such become necessary.
They should be protected, moreover, as far as possible,
against oxidation and dirt.
, The cabinet battery which I use in my own office was
made, under my special direction, by Waite & Bartlett, of
this city, and is as nearly perfect as one could desire. It
contains forty cells of the Leclanche pattern, which are
equivalent to sixty of the gravity cell. The connections
and the cells can be exposed and easily reached by remov-
ing the front and back of the case. The accompanying cut
represents its special features better than a verbal descrip-
tion. Considerable expense in constructing such a battery-
may be saved in the case, and by dispensing with some of
the accessory apparatus shown.
The gravity cell makes a very serviceable and durable
permanent battery for office work. It has one advantage
over some other cells — viz., that it has great constancy
of action and that its activity can be renewed by the ad-
dition of crystals of sulphate of copper to the fluid when
necessary without disturbing the cells. For this reason the
sulphate-of-copper cell, in some one of its various forms,
is employed exclusively in telegraphic lines. It can not
be transported, however, about the room to suit the con-
venience of the patient or the physician during his ex-
amination so well as some other cells adapted for a cabinet
battery. It is also difficult in many cases to repair the wire
connections of a fixed battery (running, as they often do,
through partitions and plastered walls to reach the key-
board) when they become inefficient from any cause,
A permanent battery is somewhat cheaper to construct
and takes up less room in the office than a cabinet, because no
30
RANNEY: LECTURES ON ELECTRICITY IN MEDICINE.
[N. Y. Med. Jouk.,
case is required ; but, in my opinion, these two advantages
are not sufficient to render it preferable to the other for
office or experimental work. I have known several of my
Fig. 27. — Large Cabinet Battery. From a photograph of one used by the author, and constructed from
designs specially furnished by him. The current-selector and rheotome differ in several respects from
those commonly used. The faradaic attachment has a Du Bois-Reymond coil. The milliampere-meter
shown in the cut is that devised by Dr. Rudisch. I am at present engaged in the construction of one
of a novel pattern, which I hope to present to the profession hereafter. The cells are of the Leclanche
pattern. The faradaic attachment is operated by a Fuller's cell.
medical friends to discard it (after a thorough trial) for
a cabinet battery. If a permanent battery is deemed pref-
erable by any of you (for reasons of your own) rather than
a cabinet battery, be sure and place your cells on shelves in
your office or waiting-room, and not in a cellar. The wires
will not be so liable to corrode from dampness, and the cells
will be constantly under your eye, so that you can see when
they require attention.
Respecting the selection of the cheaper forms of bat-
teries for general medical use, it is important that accuracy
of workmanship shall not have been sacrificed in order to
lessen the cost. The construction of the primary and sec-
ondary coils of a faradaic machine and the adaptability of
the interrupter to slow and rapid breaks in the circuit should
be looked into before a decision is reached. Poor coils and
a bad interrupter render a faradaic machine almost worth-
less. A "drip-cup" containing mercury, in which the zinc
element is placed when the battery is not in use, is a desira-
ble feature in a faradaic machine.
Do not buy a magneto-electric machine whose motor
power is furnished by a crank to be turned by the hand.
It is practically useless for medical purposes when compared
with a good faradaic instrument.
The Grenet cell is now used by
most of the manufacturers of electrical
apparatus for a portable galvanic or
faradaic battery. It is the best cell
for many reasons. A thirty-cell gal-
vanic battery gives all the current that
is required by the general practitioner.
Personally, I prefer the one made by
Waite & Bartlett, of this city, over that
of other manufacturers, on account of
its modified current-selector (Fig. 23).
It does not oxidize as do other forms
of batteries (which have a dial current-
selector attachment) when in constant
use. It is also cheaper than those
made by many other firms. Every
galvanic battery should have a com-
mutator on the key-board. Without
this appliance electro-diagnosis be-
comes difficult.
Respecting the purchase of a static
electric machine, it may be well to
state that a good one is quite expen-
sive, and is only adapted for office use.
I am convinced that static electricity
has some points of advantage which
can justly be urged in its favor as a
therapeutical agent, but it can never
be extensively employed or take the
place of galvanic and faradaic currents.
Its use unquestionably creates a pro-
found impression upon the mind and
body of the patient. He sits upon an
insulated stool, sees the " wheels go
round," feels himself getting charged
with electricity, and is made painfully
conscious of its presence when sparks of an inch in length
are elicited from his surface and through his clothing.
How much of the reported benefits derived only from the
use of this instrument are due to the mental impression so
made upon the patient is still a problem which I have not
solved to my satisfaction.
The best American instrument of this kind is probably
made by I. & H. Berge, of New York. It works well
in all weathers, and their largest machine will produce a
spark eight inches long. The electrodes for static electricity
have to be made specially for its use. They must be well
insulated by means of glass or hard rubber. Dr. W. J.
Morton * has done much to popularize the use of static elec-
tricity in this country. A water-motor is required to run a
large static machine with uniformity, although it is not ab-
solutely essential to its use in medical practice, as hand-
power will answer all practical purposes. A single-plate
Medical Record," April, 1881.
July 11, 1885.]
RAN NET: LECTURES ON ELECTRICITY IN MEDICINE.
31
machine is but a toy as a means of treatment of nervous neuralgia, I have found this form of electricity of great
diseases. Sufficient quantity, as well as length of spark, value.
is essential to the satisfactory employment of static elec- 5. In treating muscular pains and muscular rheuma-
tism, spasm, and neuralgias, I prefer the spark to in-
sulation. Patients who may have suffered for years
are frequently cured in a few sittings.
6. I prefer insulation over all other methods when
the tonic action of static electricity is desired. Cerebral
hyperemia and anaemia, headache, and vertigo are
often rapidly relieved by this method. I frequently
combine insulation with the " electric wind " (drawn
jT IJ^'lIfjffl^lffi J.J /Jlf ifT^sliP' S| '^td II t""" t'""' liead by means of an umbrella electrode) in
III IDtll jflH1 1'lilMuIVI 'i^Wjfliilla'iii:! iraJljllElllil y^>^BlillW!li!iil 1111' I'M JraPIUF these cases, as the accumulated electricity is thus con-
centrated toward the head.
7. Sparks are particularly to service in treating
numbness and cutaneous anaesthesia. I have remarked
this effect especially in the sensory disturbances which
frequently accompany hemiplegia of cerebral origin.
8. Hemiplegia and paraplegia are best treated by
means of the direct spark rather than the indirect spark.
Sometimes quite severe shocks are required before the
remedial effects become apparent.
9. Wooden electrodes are preferable to those com-
posed of metal when employed about the eye or ear,
or when the patient is very sensitive to electric cur-
rents.
10. By drawing sparks from the region of weak or
Fig. 28.— Improved Hoi/rz Static Machine (American Pattern). This form of diseased viscera, I have Sometimes noticed very apparent
machine is the best now offered to the profession. The author is at present benefits. Pulmonary, gastric, and hepatic disorders
are often directly affected by this agent when so ap-
plied. I have relieved bronchitis in this way, and
have had in some instances equally beneficial results
in thus treating nervous dyspepsia, gastralgia, torpidity
of the liver, etc. Some authors have reported beneficial
effects from this agent in the treatment of phthisis.
11. Muscular contractions can be excited by static elec-
tricity with far less pain than by faradism or galvanism.
engaged in devising some radical improvements upon the instrument which will
(in his opinion) greatly enhance its practical utility and reduce its cost.
tricity. My own machine consists of six revolving twenty-
inch plates and three stationary plates. It works well in
all weathers, and gives as large a quantity as any patient
can bear.
The following deductions express my convictions regard-
ing the therapeutical value of static electricity, derived from
an experience with it in quite a large number
of cases :
1. In certain diseased conditions I regard
its effects as more instantaneous and satisfac-
tory than those of galvanism or faradism.
2. A machine so inclosed in glass as
to prevent the action of dampness upon the
revolving and stationary plates will work in
all weathers, and is therefore free from the
most serious objection which can be raised
against franklinism. In the summer months
the dampness of the air is liable to cause
diffusion of the electricity generated by fric-
tion, and thus to render its employment upon
a patient difficult and often unsatisfactory.
3. Quantity, as well as intensity, is re-
quisite ; hence large plates, and several of
them, are preferable to any of the single-plate
machines.
4. In the treatment of muscular pains,
chronic muscular rheumatism, spasmodic af-
fections, the functional nervous diseases, and
Fig. 2!). — Drawing the Indirect Spark prom the Body op a Patient. The chain attached
to the electrode is connected with a neighboring gas-pipe or water-faucet. This cut should be
compared with Fig. 3.
32
STUB: CHOLERA ASIATIC A AND CHOLERA NOSTRAS.
[N. Y. Med. Jocb.,
The so-called " static induced current " * is a very efficient
way of subjecting individual muscles to the current when
Fig. 30.— Various Forms of Electrodes Employed with a Static Machine.
The handles are usually of glass. The author has substituted handles of
hard rubber, which do not break easily and are equally efficient for the pur-
pose of insulation.
their contraction is desired. The painlessness of this method
is a point which alone should strongly recommend it.
Fig. 31.— Morton's Spark Electrode. The sponge-covered tips may be of
any size «r shape.
12. Perhaps the most phenomenal results which have
been obtained by static electricity are achieved in the treat-
ment of hysterical patients. Hysterical aphonia, hemianses-
thesia, paralysis, and hystero-epilepsy have been cured by a
few sittings, by means of insulation and sparks.
(To be continued.)
* First described by Dr. W. J. Morton.
#rirjfmal Cffmmumcations.
CHOLERA ASIATICA AND CHOLERA
NOSTRAS ;
THEIR DIAGNOSIS AND TREATMENT,
WITH SPECIAL REFERENCE TO THE BAOILLUS*
By ARNOLD STUB, M. D.,
BROOKLYN.
Mr. President and Members of the Kings County
Medical Society : At a meeting of the Royal Medical and
Chirurgical Society of London, March 31, 1885, Sir Guyer
Hunter made the remark that he had not been able to find
a difference between cholera asiatica and cholera nostras.
Upon reading this remark, I remembered a case which oc-
curred in my own practice, and whose history tends to
support the opinion of the English physician. Permit me
to relate the case :
Monday, July 26, 1881, a prominent gentleman, closely con-
nected with one of the transatlantic steamship companies, was
taken with a light diarrhoea, which continued Tuesday and
Wednesday; a few dark-colored, painless stools and a feeling of
being tired were not sufficient to make him call for medical aid,
and he contented himself with taking a few drops of essence of
ginger and some of the so-called Sun cholera mixture, which,
however, did not relieve the disorder. After midnight, during
the night from the 28th to the 29th, his diarrhoea increased,
vomiting commenced, spasmodic contractions of the muscles of
the calves of his legs and severe griping pains created consider-
able suffering, and I was sent for.
I found the gentleman very much prostrated. Constant vom-
iting of a greenish fluid, profuse odorless alvine discharges of
rice-water appearance, a cold skin, an anxious countenance,
cold tongue, constant spasms of the muscles of the lower ex-
tremities, and extreme prostration marked the case. I ordered
at once sinapisms to various parts of the body, alternately ap-
plied, and brushing of the skin with diluted alcohol. Internally
I prescribed a mixture consisting of
01. cajeputi, -|
01. cinnamomi, \ aa gtt. xii;
01. menth. pip., J
Sp. vini gallici ^ j ;
Mist, potass, citrat usque ad. § vj.
M. S. One tablespoonful every half-hour until vomiting
ceases.
I also ordered
Mass. hydrarg gr. xx ;
Pulv. opii gr. viij.
M. ft. massa in pil. No. 8 divid. S. One pill every two hours.
Ice in small pieces to relieve thirst, hot flat-irons to the
soles of the feet, and heated flannels to the abdomen, in num-
berless other cases, had not failed to give the desired relief, and
when I called again, a few hours afterward, I expected to find
a change for the better. However, I was sadly disappointed,
and the patient remained in the same condition until next day.
On the morning of the 30th I found all the symptoms in-
creased— the vomiting and purging were almost constant, the
skin was cold and clammy, and the hands had the characteristic
appearance of those of a washerwoman. If I lifted a fold of
* Read before the Medical Society of the County of Kings, May
19, 1885.
July 11, 1885.]
STUB: CHOLERA ASIATIC A AND CHOLERA NOSTRAS.
33
the skin from any part of the hody, it remained standing in the
same position for some time. The eyes were suuken, and the
nose looked pinched. The whole face had an anxious and dusky
look, the tongue was as if paralyzed, the voice was almost in-
audible, the lips were blue, and the radial pulse could not be
felt. The vomited matter as well as the rice-water discharges
was strongly alkaline, and changed litmus-paper from red to blue.
The urine was suppressed. I ordered at once a hot bath, and
continued treatment; also ordered bags filled with hot bran to
the lumbar region. To allay the excessive thirst, I ordered the
ice to be continued. I also prescribed iced champagne and
brandy.
August 1st, the patient became still lower. The tongue and
skin were of a reptile-like coldness. A few drops of urine, drawn
with a catheter, coagulated immediately upon being heated in a
test-tube. Ordered one ounce of Tokay wine hourly per rectum,
because champagne or brandy was not retained by the stomach.
Directed another hot bath to be given, and called Dr. Hesse,
formerly of this city, in consultation.
We both came to the conclusion to try musk and camphor,
aa gr. ij, every two hours; ordered oatmeal gruel and Tokay
wine per rectum every two hours; repeated the hath in a few
hours; and continued the friction of the skin. Hot bran bags
were constantly applied to the lumbar region.
The first of the powders the patient vomited at once; the
second, given immediately afterward, he retained. Sometimes
his stomach rejected the champagne, when we alternated the
latter with iced brandy.
The following day we added strong black coffee to the
stimulants prescribed, and continued this treatment until the
eighth day of his illness, when his skin gradually became of natu-
ral warmth, his pulse noticeably of greater volume, his stomach
less irritable, his mind less confused, and his speech more audible.
During this time he had taken every twenty-four hours one
bottle of Tokay wine, with oatmeal gruel, per rectum; one
bottle of champagne and a considerable quantity of brandy by
the mouth. The urine was entirely suppressed for three days,
when it returned, and became gradually less albuminous.
After the eighth day we commenced to feed with clam-
broth, beef-tea, etc., and continued champagne and brandy ac-
cording to circumstances. Prostration still remained.
About the ninth day well-marked typhoid symptoms devel-
oped, with a range of temperature of 102° in the morning and
104° in the evening.
At the end of the second week he complained of an intol-
erable itching, particularly in the face, and, in spite of all efforts
to prevent him, he would scratch until the blood trickled down
his face. I may remark here that no opiates had been given him
for over a week. During the whole time he had been kept in
a horizontal position, and even a change of garments was effect-
ed in that position. The itching lasted for about twenty-four
hours, when all at once a furunculosis commenced, particularly
attacking the face. Some of the boils were very tardy in heal-
ing, and had an almost gangrenous appearance in the center.
The whole illness lasted five weeks, when I considered the gen-
tleman sufficiently strong to be removed to the Catskills.
Dr. Hesse, as well as myself, came to the conclusion that
this was a case identical with Asiatic cholera, although we
did not feel ourselves justified in calling it by that name,
because no other case of such a nature had appeared in the
city. We were at a loss to find symptoms for a differential
diagnosis between cholera nostras and cholera asiatica, ex-
cept from the circumstance that no epidemic cholera existed
in this country or in Europe.
I may add that from the time I made my first call I or-
dered disinfectants in the form of chloride of lime and car-
bolic acid to be used in the sick-room as well as all over the
house, and restricted the attendance upon the patient to as
few persons as possible, who avoided intercourse with the
rest of the family.
During the year 1868 or 1869 I was called upon to
see a case of sporadic cholera in consultation with the late
Dr. Barthelmess. The patient lived in Boerurn Place.
When I saw him the disease was in the algid stage, and all
I am able to remember about it is, that he died the same
day, which was the third day of his illness.
During the summer of 1866 I had spent a whole night
at a boarding-house in Flatbush, whose inmates had been
taken down with cholera asiatica. Myself and the husband
of one of the victims were the only persons who left the
house alive next morning.
I was called upon to attend the wife of this gentleman,
and found a whole house full of dead and dying without a
single attendant. If Dr. Conklin, who was health officer at
that time, happens to be present, he will perhaps be able
to refresh my memory by telling us how many people died
in that house that night.
Gentlemen, I have a very vivid recollection of that ter-
rible night and of those cases, and I assure you that I am
not able to draw a line of distinction between the cases seen
in 1 866 at Flatbush, in the boarding-house kept by the keeper
of the Penitentiary, from whence the disease had been
communicated to the inmates of the boarding-house, and
those cases of sporadic cholera which I have seen since, in
1868 or 1869, and in 1881.
The question naturally presents itself to my mind, Are
the views of Sir Guyer Hunter correct, and is there actually
no line of distinction between cholera nostras and cholera
asiatica, when the first case or cases of the latter appear in
a community like ours? I must answer this question in
the negative as long as we take the complex of symptoms
into consideration only.
But, gentlemen, within the last year or two investiga-
tions have been made into the aetiology of Asiatic cholera
which bring us a step farther toward distinguishing between
the two diseases above mentioned.
When 1 first became acquainted with the labors of Dr.
Koch, and read of his discovery of the comma bacillus, I
was enthusiastic in the belief that at last we had found the
real cause of Asiatic cholera, and, by a simple microscopical
investigation, would be able to diagnosticate cholera asiatica
from cholera nostras.
But, gentlemen, here I was doomed to be disappointed.
Then, immediately afterward, Dr. Prior and Dr. Finkler pub-
lished the result of their investigations, and proved, or at
least attempted to prove, that the comma bacillus might
also be found in cholera nostras.
Dr. Deneke found the curved bacillus in old cheese, Dr.
Lewis found it in sputa, and last, but by no means least,
Emmerich declared that the comma bacillus was not the
cause of cholera, but that a bacterium, discovered by him
in Naples, alone was the whole source of the disorder.
After I became acquainted with the foregoing state-
34
STUB: CHOLERA ASIATIC A
AND CHOLERA NOSTRAS.
[N. Y. Med. Jode.,
ments I immediately began to investigate, and spoiled about
a large boxful of covering glasses in tbe attempt to find the
comma bacillus in sputa, in old cheese, in the discharges of
cholera nostras, in chicken cholera, and in the discharges of
typhoid-fever patients.
I certainly did find curved bacilli in every one of the
specimens, but I did not find the characteristic spirillum
which I found in the preparations sent me by Dr. Nicati,
of Marseilles, and -those I received afterward through Mr.
Emmerich and Mr. McAllister, of New York, procured from
microscopical laboratories in Berlin and Brussels, and rep-
resenting comma bacilli artificially cultivated.
Although the curved bacilli found in cholera nostras and
in old cheese are also spirilla, they are of a different size and
have less of the corkscrew shape than the comma bacilli.
After the former have been prepared for the cover glass and
put up in balsam for examination, they assume partly the
form of the cholera bacillus ; but even in this condition they
are larger than the latter. But if a suspended drop from
the rice-water stools of a cholera-nostras patient and one
from the stools of a patient suffering from Asiatic cholera
are examined alongside of each other, a difference in the
size and shape of the spirilla will become easily apparent.
The spirillum of Asiatic cholera is only to be mistaken for
that of recurrent fever, and Koch himself declares that he
could not distinguish one species from the other if placed
alongside of each other.
Gentlemen, I believe that Koch is correct in reference to
his views of the aetiology of cholera and in regard to the
bacillus question. And the reason why I think so I shall
state later on.
Starting from this base, let me suppose that the cholera
raging in Spain at the present time assumes wider propor-
tions ; it spreads again to France ; it reaches Germany and
invades England. Steamers bring us within ten or twelve
days in direct communication with ports which may be vis-
ited by cholera patients at any time. One of the latter may
get on board of the steamer ; he may be well at the time
he enters the steamer ; he may be taken with a diarrhoea
during the time he is on board. According to authors, the
time of incubation may vary from one to fourteen days, and,
if this is correct, a man may travel from Marseilles to Liver-
pool or London, and from London to New York, without
having the slightest symptoms of cholera before he lands
here, or he may have diarrhoea which may pass unnoticed
by him and others ; but this man, although he may never
himself develop the second stage of cholera, may deposit
upon the steamer, or perhaps afterward in this city, the
germ which will, in a few days, infect the whole city with
the pestilence, and we may never find out where it came
from.
Now, gentlemen, let me suppose that such conditions
prevail this coming summer; we have learned that the chol-
era is in France, perhaps in Germany, but not in England.
The English steamers, consequently, are not subjected to
quarantine. All rags have been carefully excluded from land-
ing upon these shores, although I never heard that rags
had carried the disease, provided they were not wet. And
I am called, perhaps after midnight — which, by the way,
seems to be the time such cases first become most trouble-
some— to see a patient who suffers from symptoms of chol-
era. The question naturally arises, Have I to deal with a
case of cholera morbus or cholera asiatica ? The question is
an important one. Shall I notify the Board of Health, and
perhaps unnecessarily alarm the community ? Shall I isolate
the patient, or shall I let matters go on, wait for develop-
ments, and jeopardize the lives of other people ? In order
to come to a proper diagnosis of the case, I proceed at
once to look for the cholera bacillus in the rice-water dis-
charges. In three different ways this object may be at-
tained. I take two covering glasses, clean them well, after
the most approved method, in nitric acid, wash them in
alcohol and in ether, and afterward in distilled water.
As soon as they are dry I place a drop of the rice-water
discharges upon one of those glasses with a spatula, pre-
viously sterilized by heating it over an alcohol-flame or a
Bunsen burner, and spread the drop of the rice-water dis-
charge carefully out upon the covering glass. I place the
second glass upon the first and draw them asunder, in order
to cause an even and uniform spread of the material upon
both glasses.
As soon as they are completely dried, which will be in
a few minutes, I draw them slowly three times through the
flame of an alcohol-lamp, holding them with a pair of for-
ceps covered side upward. Then I take them home and
heat in a test-tube a small portion of a watery solution of
gentian violet or fuchsin. As soon as the fluid begins to
smoke, I pour some of it into a watch-glass, and, taking the
covering glasses between two fingers, I let them drop upon
the fluid with the side containing the suspected material
downward. I let them swim for about ten minutes, take
them from the fluid, wash them in sixty-per-cent. alcohol
for about two minutes, remove the water by dipping them
for a few seconds into absolute alcohol, wait a few minutes
longer until they are dry, and then examine them under
the microscope with a power of water immersion, or,
better still, with ^ oil immersion, and expect, of course,
to be able to diagnosticate, from what I see, true Asiatic
cholera or cholera morbus.
But, gentlemen, although the method above described
is exactly the one used by Koch to bring the comma bacilli
into view, if the material is taken directly from the patient,
or if taken from an artificial cultivation, I may be sadly disap-
pointed in all probability, because, in the first place, I may
find no characteristic spirilla, and those bacilli we do find
may belong, as far as their microscopical appearances show,
just as well to cholera morbus ; or I may find only straight,
rod-like bacteria mixed with a few curved ones, such as
can be seen in all the excrements of ordinary diarrhoea;
because it is a well-established fact, I think, that in the be-
ginning of Asiatic cholera the characteristic spirillum can
not be immediately recognized under the microscope. A
better method, however, would be to place a drop of rice-
water discharge upon a covering glass, and put the latter,
with the drop of fluid downward, upon a shallow glass cell ;
if this suspended drop, which may be stained with one of
the basic aniline colors, is examined with a powerful immer-
sion lens, it is possible that we may find sufficient evidence
July 11, 1885.]
STUB: CHOLERA ASTATIC A AND CHOLERA NOSTRAS.
35
to base a diagnosis upon. We shall see at least a large
quantity of bacteria alive, and, if the fluid contains a suffi-
cient quantify of the cholera bacilli, they will appear like
a swarm, of mosquitoes moving hither and thither, and
among those there will be noticed occasionally a few spirilla
of a wave-like form. So, at least, does Koch describe the
microscopical appearance of a suspended drop of artificial
beef-tea cultivation, and there is no doubt that the same
may be observed if rice-water discharges are used for ex-
amination from a patient who has been sick for some time,
but it is very doubtful if we shall be able to gain this result
in the earliest stage of cholera.
Another method of distinguishing the cholera bacilli is
published in the " Deutsche medicinische Wochenschrift,"
Berlin, April 2, 1885. Professor Max Schottelius, of Frei-
burg, went to Italy to study the cholera, and, being ad-
mitted into a cholera hospital of Turin, he made numer-
ous investigations. The principal result he obtained is
the following: He mixed 100 to 200 c. cm. of the sus-
pected faecal matter, or rather rice-water discharge, with
250 to 500 c. cm. of slightly alkaline meat-broth. This
mixture must be shaken and put into a high beaker-glass.
The glass must be put in a warm place, the temperature
of which does not exceed 40° C, or 104° F. The fiuid
remains standing for from ten to twelve hours. After this
time the surface of the fluid is touched with a ijlass rod, and
a drop placed upon a covering glass; further preparation,
and staining with a concentrated watery solution of fuch-
sin, as described before, will, under the microscope with a
power of about 600 diameters, show almost a pure cultivation
of the comma bacillus, if the case has been genuine cholera.
Examination of a suspended drop of this mixture gives also
a characteristic and perhaps still better demonstration. The
surest method, however, suitable for diagnostic purposes, will
be the cultivation with nutritive gelatin upon glass plates,
and we shall find it of sufficient simplicity to make practical
use of it, provided we are able to obtain at short notice the
necessary nutritive gelatin of slight alkaline reaction. I
herewith will mention briefly two formulae found to be most
efficient for use: First, 17 ounces of good, finely chopped
meat, added to 34 fluidounces of distilled water, and well
stirred, remains standing in the ice-box for twenty-four
hours. Afterward the whole is strained through gauze by
means of a press, and sufficient distilled water added to
make again 34 ounces. To this must be added '2\ drachms
of table-salt, and from 1^ ounce to 3 ounces of the purest gela-
tin ; allow the whole to dissolve by gentle heat, neutralize
with carbonate of sodium, and add a little of the latter in ex-
cess to give the mass a weak alkaline reaction, sufficient to
turn red litmus-paper slightly blue. The neutralized solu-
tion must be boiled for an hour upon a water-bath and, still
hot, filtered through paper. The filtrate, boiled again and
afterward put upon ice, must be clear and transparent. Dur-
ing the boiling process a turbidity, caused by phosphates,
may appear, which, however, will disappear as soon as the
gelatin has been cooled upon ice.
Another process, described by Dr. F. Hucppe, professor
of hygiene and bacteriology at the laboratory of Fresenius,
of Wiesbaden, is the following : Peptone, 3 p. c. ; grape-sugar,
0-5 p. c. ; extract of meat, 0-5 p. c. and from 5 to 10 p. c.
gelatin. I will not try your patience by giving the whole
process necessary for this preparation. It will be sufficient
I think, if I mention that a little apparatus is required and
a great deal of exactness and time. We, as practical physi-
cians, may have the former, but hardly the latter, at our
command, consequently I would like to take the liberty of
suggesting that Dr. Squibb, for instance, take the matter in
hand and prepare for us the gelatin, or that the Board
of Health establish a laboratory where not only shall the
gelatin be prepared, but, under the supervision of a compe-
tent medical man, such investigations carried out as I have
already suggested or shall hereafter describe.
Supposing we are in possession of the necessary gelatin
and desire to make the cultivation as above mentioned. For
this purpose we take an object-glass, according to the size
of the stage of our microscope, to enable us to examine the
same afterward in all directions with a lens. We put some
of the nutritive gelatin into a test-tube and warm it in hot
water until the gelatin becomes fluid ; then, by means of a
pipette, we carefully transfer some of the gelatin to the ob-
ject-glass.
The portion of gelatin transferred must be a few milli-
metres thick and no part touch the edge of the object-glass.
Then we take, with a sterilized platinum-wire, a drop from
the rice-water discharges, and inoculate the gelatin by
making a few strokes upon it of not sufficient depth to
reach the glass below the gelatin.
The longer our object-glass, the more strokes we shall be
able to make, and the easier it will be to recognize and dif-
ferentiate the colonies of bacteria which will grow there.
After the gelatin has been inoculated, the plate of glass
must be placed under a bell-glass whose walls are dampened
inside with distilled water. This, however, is not absolutely
necessary. Eighteen hours afterward we shall observe the
result of the inoculation by the growth of the different spe-
cies of bacilli. In case of Asiatic cholera we shall observe
in the early stages of the growth a small, pale drop, not of a
perfectly circular appearance, such as almost all other colo-
nies of bacteria present, but with irregular, rough edges.
From the very beginning of its growth it has a granu-
lated appearance. A few hours after the first appearance
of these drops upon the gelatin the granulation appears
more marked, and looks like a mass of irregular-shaped,
highly refractive granules, which Koch compares to a lit-
tle pile of small pieces of glass. Within twenty -four hours
the gelatin becomes fluid in the immediate neighborhood of
the colony, and the latter sinks deeper into the gelatin. A
small funnel-shaped impression is formed, in the midst of
which the colony may be seen as a small whitish spot or
dot. Forthe purpose of making these observations, the -lass
plate must be placed under a microscope and examined
with a power of about eighty diameters. In order to make
these cultivations, a temperature not lower than 68° F. is
necessary, which during the summer months will be easy to
reach. In case we have to deal with a cultivation of the
bacilli of cholera nostras discovered by Finkler and Prior,
we shall find discs of a regular, even shape, and within thirty
hours a funnel of 1 cm. in diameter will have formed, which
3(3
BURKE: FRACTURE OF THE SKULL.
[N. Y. Med. Joub.,
in two or three days will have widened out to such an ex-
tent that the whole of the gelatin will have flowed off from
the object-glass.
(To be concluded.)
A CASE OF COMMINUTED AND DEPRESSED
FRACTURE OF THE SKULL; TREPHIN-
ING; FUNGUS DUR^E MATRIS; RECOV-
ERY.*
By W. C. BURKE, Jr., M. D.,
SOUTH NORWALK, CONN.
0. R., aged eleven, was struck by a locomotive attached to
an express-train, running at a high rate of speed, on the after-
noon of November 6, 1883.
He sustained a compound comminuted and depressed frac-
ture of the left temporal bone, involving slightly the frontal and
parietal bones of the same side. The blow was given while the
boy was in the act of jumping from a car directly in front of
the approaching train, which he did not see. He was thrown a
considerable distance to the side of the track, and, when picked
up, was unconscious, breathing stertorously, and bleeding pro-
fusely from the divided temporal artery. He was taken to the
accident-room at the station, and seen by me within ten minutes
after the accident. At this time the pulse was very feeble and
slow ; breathing stertorous ; pupils moderately but unequally di-
lated, the right more than the left. The wound was cleansed,
the bleeding vessels were secured, a temporary dressing was put
on, and he was conveyed to his home a mile distant. He had
lost a good deal of blood.
An hour later, with the assistance of Dr. J. G. Gregory, I
removed the dressings, and, enlarging the opening in the scalp,
found that the skull had been fractured and depressed over an
area two inches by two and a half, located a little above and in
front of the left ear. The fractures did not extend beyond this
oval in any direction. I found nearly all the pieces of bone
lying loose in the wound, and they were easily removed. After
removing all the fragments in sight and carefully cleansing the
exposed membranes, I found a gaping wound of the membranes
and brain substance. Gently insinuating my little finger into
this opening, at the depth of an inch and a half from the surface
of the skull, I felt two pieces of bone, which I cautiously re-
moved, carrying the slender forceps along my finger as a guide.
They proved to be fragments of the internal table of the skull
turned edgewise and in their long diameter, evidently shot into
the brain by the blow, like flying glass. These increased the
depth of the wound by nearly an inch, making the wound of
the brain about two inches and a half deep. The direction was
obliquely downward and backward toward the pons Varolii.
Considerable haemorrhage from the brain substance was con-
trolled after some delay. Two vessels in the external wound
required ligatures.
Just as I was withdrawing the last fragment from the
wound the patient gave the first symptom of returning con-
sciousness. He groaned and turned his head partially to the
left. After careful cleansing of the membranes they were
smoothed out, everything being left in as natural a condition as
possible, and the external wound was closed by fourteen inter-
rupted sutures.
A compress, wet in a five-per-cent. solution of carbolic acid
and secured by a roller bandage, completed the dressing. These
dressings were to be moistened repeatedly during the night
with the solution. He rallied well from the shock, but passed
a restless night, tossing about a good deal. Sixty-nine hours
* Read before the Brooklyn Pathological Society, February 12, 1886.
after the accident he uttered his first coherent sentence, al-
though he had spoken detached words twenty-four hours pre-
vious. Everything progressed favorably, the wound apparently
healing well. On the sixth day I removed a part of the stitches,
and the remainder on the seventh. When union had taken
place throughout, except at the point of exit of the two liga-
tures, a piece of rubber tissue was laid next the wound, and
over this several layers of gauze secured by the roller. The
next day the dressings were not disturbed. On the ninth the
boy complained of a pain in the wound, and the dressings
bulged at the seat of injury. On removal, a cauliflower-like
growth, protruding three eighths of an inch above surrounding
scalp, had reopened the wound to the extent of the opening in
the skull-bone. The edges were everted so that its diameter was
a little over three inches. In the afternoon of the same day I
attempted to remove a portion with the galvano-cautery, but
with only partial success. Several things were tried in the next
day or two, but were of no avail.
The growth by this time had increased to formidable pro-
portions. I then determined to try the dried sulphate of zinc
upon it. So I put on a free coating of this, and over it a com-
press and bandage, drawn as tight as the patient would allow,
which was not nearly so firm as I should have preferred, as he
complained that it gave him "a feeling in his head of bursting."
This dressing was allowed to remain forty-eight hours, when,
on removal, I was pleased to find a slough, three eighths of an
inch thick, easily removed. Another coating of the zinc was
put on and similarly dressed, remaining forty-eight hours. This
process was continued until all the diseased tissue had been
removed down to the level of the healthy brain substance, when
the zinc was discontinued and iodoform substituted. When the
dressings were again removed, healthy granulations had sprung
up all over the wound, and the process of repair went on as
rapidly as could be desired. The constitutional treatment had
been with iron and quinine — in short, supportive.
At no time had the temperature been above 101° F., and
that only once, during the first forty-eight hours. A slight
amount of brain substance had been lost. He was discharged,
January 25th, two months and nineteen days after the accident.
A recovery from so frightful an accident is rare when
we consider the extent of injury to the brain substance, the
wound extending well toward a region of the cerebrum
usually considered vital. And the recovery from fungus
durse matris was hardly less remarkable. There were, I be-
lieve, fifty-one cases of this disease following wounds of the
brain during the late war, in which forty-five of the patients
died, only 1*13 per cent, recovering. The boy is in perfect
health now, and has no headache or other unpleasant symp-
toms. Mentally, no special change is noticeable ; but his
teacher thinks he does not commit to memory with quite so
great facility as before the accident. But even this is doubt-
ful.
ON THE ERADICATION OF SYPHILIS DUR-
ING THE FIRST STAGE BY SURGICAL
MEANS*
By A. H. P. LEUF, M. D., Brooklyn,
PATHOLOGIST TO ST. MARY'S GENERAL HOSPITAL, TO ST. MART'S FEMALE HOS-
PITAL, AND TO THE HOSPITAL FOR NERVOUS AND MENTAL DISEASE, ETC.
Inasmuch as it was originally planned that this paper
should not appear till the end of this year or the beginning
* Read before the Medical Society of the County of Kings, May 19,
1885.
July 11, 1885.J
LEUF: THE EARLY ERADICATION OF SYPHILIS.
37
of the next, I am enabled to give but an outline of what it
is ray intention ultimately to say upon this subject. Being
but the outline of an argument in favor of a specific thera-
peutic measure, it will uecessarily be very brief. For the
purpose of economizing time, I will purposely avoid refer-
ence to authors and the discussion of the various views held
upon this interesting and intricate question. Various, how-
ever, as are these views, and great as may be the intricacy
of this subject, it is yet possible to reduce them to simpler
proportions for convenience of analytical study and syn-
thetical deduction. My plan, therefore, this evening, will
be to submit to you only that way of viewing this question
which accords with my argument, and the digressions there-
from shall be as limited as possible for the purpose of sav-
ing time.
Syphilis is a constitutional disease and contagious in the
true sense of the word ; that is, communicable only by con-
tact, and therefore produced invariably by inoculation — ex-
cept it occasionally be autogenetic. It is preceded by a
period of incubation, and manifests itself in three periods —
primary, secondary, tertiary.
The primary stage consists in the formation, growth, and
decadence of a highlv characteristic sore at the seat of in-
oculation after an average incubation of much longer dura-
tion than precedes any other sore with which it might be
confounded. A variable time after the formation of this
sore, or chancre, the nearest set of [lymphatic glands be-
come enlarged.
The secondary stage is ushered in by acute characteristic
general signs and symptoms after a definite interval, meas-
ured by weeks, succeeding the appearance of the chancre.
This continues for a variable time, to be followed by a period
of quiescence, usually measured by months.
The tertiary stage exhibits itself in the form of special
pathological changes in one or a number of places, and either
in one or a number of tissues, at the same time or at differ-
ent times. These manifestations are mostly dependent upon
their location for their greatest significance. Thus, a nodu-
lar enlargement of the tibia is in itself harmless ; long radii
of the calvaria perhaps the same, but for the proximity of
a vital organ ; an exostosis within the lower part of the
spinal canal, although similar in character, is not now so
harmless, but, if sufficiently large, will induce paralysis of
the parts below ; the same projecting from the walls sur-
rounding the medulla has a significance that is fatal ; even
in this latter instance the effect may be nil so long as the
growth does not continue beyond a certain size. This is the
general character of tertiary manifestations. A carcinoma
of the breast will kill by its virulence and not by its increase
in size, while the converse is essentially true of syphilitic
formations.
Thus we understand that the existence of syphilis is a
constant menace to the body it inhabits. Of the nature of
its active principle nothing definite is known. One fact is
quite universally admitted, and that is, that, when inocula-
tion has once taken place and the chancre is formed, second-
ary symptom^ demonstrating systemic infection are inevi-
table, and so, as a rule, are tertiary manifestations in the
majority of cases.
As rational therapeutics preponderates over empiricism,
it becomes more evident that aetiological data increase in
value for the treatment of disease. A thorough comprehen-
sion of these is impossible without an exact knowledge of
the minute pathological changes that accompany disordered
states of the body. In syphilis we have no knowledge of
the character of the virus itself. Its manifestations are
known to us both macroscopically and microscopically, the
latter especially in the tertiary forms. The changes it in-
duces at the beginning, in the formation of the primary
lesion, are not so well understood nor so generally ac-
cepted.
To adopt a rational plan for the interception of this
poison previous to its geueral invasion of the body, the fol-
lowing questions must be answered :
1. Does the disease arise de novo — is it autogenetic ?
2. What are the necessary conditions for inoculation ?
3. What is the effect of the virus at the seat of inocu-
lation ?
4. Is there a decided interval between local and sys-
temic manifestations?
5. By what channels does the disease enter the system
by the blood or by the lymphatics ?
6. Can the progress of the virus be traced from the time
and place of its entrance into the tissues until general in-
fection has occurred ?
That all this can be done I shall now proceed to demon-
strate :
1. Does the disease arise de novo — is it autogenetic ?
Syphilis must have originated at some period, and at
not so remote a day but that the circumstances existing at
that time to favor its production must also exist at the pres-
ent day. Therefore I can not deny the possibility of its
occasional spontaneous origin, although compelled to admit
that it must be a comparatively rare occurrence.
2. What are the necessary conditions for inoculation?
These consist in the presence of the virus and stable
living cells in direct contact. The cutis being composed
of dead, and to some extent desiccated, cells, it is evident
that inoculation can not take place through it. Observation
demonstrates that this is true, for the rule is, in carefully
studied cases, that a denudation of the cutis vera is a con-
stant and necessary precursor of the chancre. I will relate
an incident in point :
Two medical students, at a Western university, spent a
night together in the same bed with a woman of obtuse
morals. Neither student had had any sexual congress for
several months preceding this night, nor did they during a
long period subsequent. One developed a chancre, and,
later, secondary symptoms ; the other never suffered the
least local or general disturbance. Circumstances would
not warrant the supposition that the chancre developed de
novo. On the other hand, it would be contrary to clinical
observation and the result of scientific experimentation to
suppose that the more fortunate student escaped because he
enjoyed a special immunity, for he had never had syphilis.
The correct solution of the problem lies in the assumption
that the one affected had abraded a portion of the mucous
membrane of his penis while the other had not, and this
38
LEUF: THE EARLY ERADICATION OF SYPHILIS.
[N. Y. Med. Jodb.,
was actually the case. This is not a lone instance ; there
are many others.
The denudation of the cutis vera — an abrasion, in other
words — is, therefore, necessary for the introduction of syphi-
lis through the skin or mucous membrane ; that is, direct
contact between the virus and the stable living cells.
3. What is the effect of the virus at the seat of inocula-
tion ?
It gradually, but inevitably, induces circum scribed tissue
changes of a special character, which become evident only
after a lapse of time varying from a little more than a week
to more than two months. The tissue changes consist
mainly of a proliferation of the vessel-walls and immediate
fixed cells, without the usual amount of serous effusion and
byperaemia. They manifest themselves in the form of an
elevated ulceroid, with a hard base, and having a serous
rather than a purulent discharge. The variation in the
time at which the initial lesion appears after inoculation is
due more, if not entirely, to its location with reference to
the lymphatic vessels than to various grades of suscepti-
bility by some supposed to exist in the individual. This is
also especially true as regards the length of the interval be-
tween the appearance of the chancre and the onset of sec-
ondary symptoms.
4. Is there a decided interval between local and systemic
infections ?
An affirmative answer to this question will be gainsaid
by no one. An intermediate manifestation, however, is ap-
parent between these local and general disturbances, and it
shows itself in the first set of lymphatic glands reached by
the lymphatic vessels beginning at the seat of inoculation.
The time at which these glands show evidence of participa-
tion in the syphilitic process varies. Enlargement may
commence shortly after the formation of the primary lesion
or within a brief period Before the onset of general second-
ary symptoms. There can be no doubt, though, about there
being a distinct interval between local and general infection.
The action of the lymphatic glands leads to the next ques-
tion.
5. By what channels does the disease enter the system —
by the blood or by the lymphatics ?
By the blood ? — When we consider the rapidity with
which the blood flows through our bodies, and the uniform
results obtained in producing rapid effects by intra-san-
guineous injections, it is impossible to reconcile these well-
established facts with the comparative exceeding slowness
of general syphilitic infection, unless it be on one ground.
This would be that a second incubation takes place in the
blood analogous to that at the point of inoculation, or that
the period of incubation of the virus in the blood is longer
than that among the stable cells; but this would be con-
trary to all known physiologic laws and processes. Were
the blood-vessels and their contents the distributing chan-
nels of this poison, the general infection of the patient
would not be so long in taking effect, nor would it be inter-
rupted. The blood is not the channel by which the virus
enters the system.
By the lymphatics? — We all know, from the results of
investigation in the physiological and pathological labora-
tories, as well as clinical experience, that the blood is the
body's distributer of food and air in its passage from the
heart, while on its return it renovates the tissues by the ab-
straction of those impurities that are the natural result of
physiological metamorphosis. The lymphatics, on the con-
trary, among other things, perform an interceptive function
in preventing or retarding the entrance into the circulating
blood of those deleterious substances for the elimination of
which there appears to be no special provision. Thus, al-
though carbonic oxide and urea arc very poisonous, they
enter the blood to be promptly excreted, the one by the
lungs and the other by the kidneys ; there is a special pro-
vision for their elimination, as they are a normal, constant,
and necessary product. Contrariwise, the virus of carcino-
ma is not the outcome of normal, constant, and necessary
physiological activity, but the result of changes that are ab-
normal, inconstant, and decidedly unnecessary, and hence
has not provided for it a special and normal eliminative or-
gan. If it once enters the blood, it will remain and spread
disaster. It only gets there insidiously. The blood does
not take it up. Lymphatic vessels which ramify through-
out the body and lymph-spaces existing in nearly all the
tissues absorb this product of unusual and abnormal meta-
morphosis and conduct it to the first set of lymphatic
glands. Here it is retained as long as the gland is capable
of holding it, and, when this retentive function becomes in-
efficient, the poison passes into the blood, and the general
infection of the individual is the immediate and inevitable
result.
It is through the lymphatics, then, that syphilis enters
the system, although retarded in its progress through the
glands. \
6. Can the progress of the virus be traced from the time
and place of entrance into the tissues until general infection
has occurred?
This is possible, and it occurs in the following way :
As soon as the poison comes in contact with the living
cells it sets up an irritative process, which, in consequence
of its persistence and special qualities, eventuates in the pe-
culiar cell proliferation that gives rise to the initial lesion
of syphilis. This cell formation is peculiar in that it in-
volves the vessel-walls, causing them to grow eccentrically
as well as concentrically, thus giving rise to an increase in
their external diameter coincident with a diminution of cali-
ber. Many detached cells and nuclei are to be found within
the lumen of the capillaries obstructing the flow of blood.
The immediate fixed connective-tissue cells also participate
in the proliferating process, and to such an extent that the
intercapillary spaces become packed with these new forma-
tions. In consequence of the diminished caliber of the
vessels, there is an absence of the degree of hyperemia so
common in pathological cell formations. Serous effusion is
also lacking on account of the scanty blood-supply and the
thickening of the vascular walls. Those compacted cells
which are on and nearest the surface, being enabled to im-
bibe their nourishment from all directions except one, die
and fall off from this side — that is, die at the surface. Con-
siderable pressure is exerted within this cell accumulation
and causes the contained serum to find its way out through
July 11, 1885.]
LEUF: THE EARLY ERADICATION OF SYPHILIS.
39
the surface breach, in which direction evidently is the least
resistance. The induration of this, the chancre, is due to
the close packing of the cells, the lessened blood-supply,
and the spare amount of serous effusion. The long con-
tinuance of the induration after it has healed over is also
accounted for by the diminished local circulation and ab-
normal condition of the vascular walls as being a decided
interference in carrying on any absorptive process.
The lymph-spaces and vessels in contact with these new
products absorb the virus and convey it to the nearest
lymph-glands. Here the virus is arrested and tends to set
up a process identical with that existing at the place whence
it just arrived. Eventually this is accomplished as well as
it is possible in a different tissue. The result is an enlarged
and indurated gland. We all know, too, how hard are
these glands and how hard is the chancre. The typical
primary sore does not really suppurate, for it simply throws
off superficial layers of cells and debris with a limited
amount of modified serum. A fact that is interesting to
note now is that the glands involved, although enlarged and
indurated, rarely suppurate.
The production of leucocytes constitutes one of the
functions of lymphatic glands, and from them the white
corpuscles are at once admitted to the circulating blood. It
is evident from this that, after a brief residence in these
glands, the poison will be admitted to the blood and per-
vade the whole body. The glands, however, as a rule, either
destroy the virus they have brought to them, or render it
innocuous, but not in all instances. It is hardly necessary
to remark that in the case of syphilis we have a notable
exception to this rule, but not without compensatory action
of the gland — to wit, the retention of the virus for a suffi-
cient length of time to admit of its mechanical removal.
When the virus has penetrated those parts of the glands
which are about to be launched into the circulating blood,
the first step toward general infection has been taken. Ad-
ditional loads of virus are thereafter constantly being thrust
into the circulation and carried by it to all parts of the
body. The other lymphatic glands being more susceptible
to the influence of this and similar poisons than an)' of the
other tissues, it is but natural that a general glandular dis-
turbance should note the beginning of secondary symptoms,
and that is actually what occurs in most instances. That
the more superficial glands should be the ones mentioned as
being enlarged at this time is only natural, for the deeper
ones are not felt by the physician. Therefore does it happen
that we are usually told that the cervical and supra-troch-
lear glands are the ones most commonly found enlarged at,
or just preceding, the onset of secondary symptoms.
When we consider that of all disorders, excepting
phthisis, there is probably none that is so malign in its
effects upon our species as syphilis ; when also we regard
the fact that a very large proportion of the victims of this
affection are a prey to heredity ; and when, lastly, we reflect
upon the present utter impossibility of preventing a general
systemic syphilitic infection, and that" too in defiance of
valuable palliative medicinal resources — I say, then, it must
be admitted that any therapeutic measure that may be pro-
posed for the eradication of syphilis previous to systemic
infection is justifiable, if based on rational grounds. Not
only is it justifiable, but it is unmistakably our duty to
attempt these means if they give a reasonable promise of
success.
In the light of established facts, it is hard to believe
that well-informed men still exist who will not admit the
purely local nature of the chancre and resulting enlarge-
ment of the nearest lymphatic glands. It is a widely known
fact that a person having syphilis is unable to develop a
second primary lesion so long as he gives evidence of exist-
ing constitutional infection. Less widely known is the
equally well-established fact that additional chancres may
be developed ad libitum up to a short time before the out-
break of symptoms denoting constitutional infection.
In fact, the strongest claim for the curability of syphilis
is based upon this very fact of a person with general symp-
toms being uninoculable with the same disease. He enjoys
absolute immunity from additional infection, and must be
cured to be at all susceptible of reinfection and the develop-
ment of a second chancre after having once suffered consti-
tutional syphilis.
If this is the correct view, and surely it is the most
reasonable one, it is equally as certain that constitutional
syphilis does not exist up to a short time before the second-
ary eruptions, because a second chancre or series of chan-
cres may be developed either by. auto-inoculation or hetero-
inoculation during this particular period.
In the treatment of any disease, it should be our first
effort to attempt its abortion, and of none can it more truly
be said that such attempt is our first and imperative duty
than syphilis. Complete excision of all the structure har-
boring the virus while it is still local would positively abort
the disease. At present it appears that the chancre and
nearest set of lymphatic glands are the only structures
affected during this primary period. Their thorough ex-
cision promises to effect the immediate termination of the
disease, if accomplished sufficiently early. I should call
sufficiently early any time previous to the appearance of
secondary symptoms, and while the glands were still not
much enlarged. All measures of this kind would be, how-
ever, absolutely contra-indicated after the outbreak of the
secondary stage.
As regards the mode of operating, I think one thing
very important and essential to success. It is that, inasmuch
as glandular infection is due to material coming from the
chancre, the safest way would be to remove the primary
sore first and the glands afterward. Then, again, as the
virus traverses gland after gland in regular order, reaching
the one farthest removed after it has affected the nearer
ones, it would be most safe to begin the glandular excision
with the removal of the most distant one first and endinsr
with the nearest and first affected.
I recognize at once one possible source of failure in this
treatment, and that is that some of the virus may be -re-
tained in the lymphatic vessels between the excised sore
and glands and permit of its absorption through collateral
channels. This is guarded against, as far as possible, by
the elimination of the active source of infection, the chan-
cre, before the absorbents are cut off from their receiving
40
CURTISS: IMMUNITY IN DISEASE.
[N. Y. Med. Joor.,
glands. Perhaps it would be well to allow several hours to
elapse between the excision of the sore* and of the glands,
so as to admit of the convergence of all the virus in the
lymphatics to the glands about to be extirpated. Or, best
of all, it would be most advisable to excise all the lym-
phatics between the chancre and glands if at all affected,
and possibly it would be still better to always excise these
vessels, whether they appear to be affected or not.
Only clinical experience and experimental research can,
however, positively settle this point, and it is for the pur-
pose of gaining this valuable experience as soon as possible
that I have thus early offered this paper. If every man
will cast aside his prejudices and attempt this abortive
treatment of syphilis, we shall soon see demonstrated the
fallacy or correctness- of this view. That it will prove cor-
rect I have not the least doubt. It is only necessary to
cast our eyes about and note the increased percentage of
cures from carcinomatous excisions, since complete extirpa-
tion of the whole set of lymphatic glands nearest the neo-
plasm has come into vogue, to gain hope and confidence
for the method of cure herein advocated. These glands, be
it remembered, in operations for carcinoma, are thoroughly
excised, although very often without the slightest evidence
of disease. We have but to recollect the character of
syphilis and its associations to feel the deepest commisera-
tion for the innocent progeny who inherit the disorder.
For this reason alone, if for no other, every rational means
ought to be tried, and is justifiable, to prevent its spread
not only around us but to future generations.
Perhaps many former advocates of chancre excision will
be opposed to this abortive plan of treatment because of
the almost generally conceded failure of that half-way the-
. rapeutic measure. Yet even this method may be all that is
necessary in rare instances where the glands have not yet
received any of the virus. I am willing to believe that
some of the reported cases of cure in this way were actual
instances of aborted syphilis. It is to be hoped, therefore,
that those gentlemen who once championed chancre ex-
cision, and, of course, those who do so still, will be the first
to take in hand the practical testing of the more thorough
method it seems to me so proper to advocate.
Deeming the foregoing sufficient an outline to subserve
the purpose of creating intelligent discussion on this question,
I will complete my remarks with a few additional statements.
My object has been to be fair and temperate in all that
has been said. Although readily admitting plenty of room
for honest differences of opinion in more than one part of
my argument, I have refrained from attempting a systematic
refutation of everything that seemed inconsistent from my
standpoint, as it would only have interfered with the real
objects of this paper. It is also well to recollect that the
deductions I have made are based on the rule of behavior
in syphilitic processes and their manifestations. Excep-
tions to these general rules in the clinical history of this
disorder are many and various, yet, if thoroughly analyzed,
will be found to have no confuting effect upon the preced-
ing argument. Even this, though, is only a rule, and also
may have its exceptions, and exceptions, be it remembered,
are often proof that rules exist.
I have been as general as possible in the treatment of
this question instead of being more specific, so that it
should have the widest application and be followed by the
broadest and most profitable discussion. The failure to
mention the names of authors, or relate interesting and im-
portant experiments and cases, must not be construed in
any other sense than that the object was to avoid undue
complexity and to save time. The great and only point at
issue in the discussion of this question is, How soon after
inoculation does systemic infection occur?
In the hope that the discussion of this question will be
frnnk and constantly to the point at issue, I have the honor
of submitting to your judgment this argument on the earl)'
and prompt eradication of syphilis for all that it is worth.
IMMUNITY IN DISEASE.
By ROMAINE J. CURTISS, M. D., Joliet, III.,
PROFESSOR OP HYGIENE IN THE COLLEGE OF PHYSICIANS AND SURGEONS,
CHICAGO.
The paper read by Dr. R. G. Eccles before the Brook-
lyn Pathological Society, and published in the " New York
Medical Journal," May 23d, refers to a subject which must
eventually be settled. People will never be contented with
the phenomena of disease, in relation to the causes, without
a generalization which will cover the whole group of phe-
nomena. The hypothesis of gravitation and that of the ex-
istence of a light-ether explain the phenomena of the uni-
verse relating to the motions of the spheres, and also the
phenomena of light. What gives immunity in disease, what
causes disease, and how do the causes act ? are leading ques-
tions that must all be grouped together under one generali-
zation which can explain them all, and I take it that any
contribution looking to this end will be welcome to the
profession.
Before proceeding to actual work, it may be useful to
examine the methods of doing this particular kind of work
— to get the tools in good working order. I believe it is
understood that whatever classes, orders, or varieties of
things or phenomena we are studying — whether they be
affairs of common life, or any special science, or whether
the most complex questions that confront the philosophers-
one of the objects of our study is to generalize laws from the
things or phenomena, and the method or tool with which we
work is hypothesis. It is a " cut-and-try " method. The
hypothesis is designed to occupy the place of a general
cause or antecedent to the whole group of questions under
consideration. In selecting an hypothesis, care is required
to be certain that the selection is a real cause in Nature, or
else can be proved to be, and, when the selection is made,
it appears that we have the question to settle next that the
hypothesis is capable of causing such results as we are
studying, and at the same time it must be proved that other
supposed causes, or hypotheses, are not sufficient.
I think this is a fair conception of the method employed
in the study of all things and phenomena, including dis-
ease ; and now, before proceeding further, it is necessary to
define what is meant by immunity from disease.
This inquiry being limited to the zymotic diseases, the
meaning of immunity from disease must be that the organ-
July 11, 1885.]
GURTISS: IMMUNITY IN DISEASE.
41
ism can by soma means resist the living agent of disease.
The power of resistance, whatever it may be, is acquired,
as we certakily know, by an attack of the disease; and it is
known that this power is also acquired by heredity. A
person may be exempt from the attacks of given species of
parasites, by reason of a former battle with the same species,
or a variety of the same species, or the person may have
immunity from the successful attacks of these enemies which
he obtained by heredity from a long line of parasite-pestered
ancestry.
Unless it can be proved that people inherit the actual
germs of disease, the law of heredity must impose the in-
ference that, instead of inheriting a disease, persons inherit
an immunity from disease, or else fail to inherit the immu-
nity. The heredity of disease would appear to be negative —
that is, a person inherits the disease simply because he fails
to inherit an immunity. This view of the question of he-
redity will fully explain the fact that consumptives and
syphilitics and'thc victims of other hereditary diseases are
the victims of these diseases because their ancestors have
not acquired, by natural selection or by actual combat with
the infectious causes, an immunity from the diseases.
We know very well that immunity from such a disease
as small-pox in an individual is acquired by an actual com-
bat with the infectious cause of small-pox. The inference
must follow, therefore, that the people who escape the zy-
motic diseases, by reason of personal immunity or by reason
of a successful vital or physical resistance to the germs, do
so not because they have failed to encounter the germs or
failed to inherit them, but because they have inherited the
physical resistance from ancestors who acquired the same
by reason of having the disease.
But we find that immunity from disease has quite indefi-
nite relations to time. In a certain ratio the immunity lasts
a life-time, but in a far larger ratio it lasts for only a year
or a few years. Probably, if an average could be known, it
would be found that seven or eight years would express it.
Now, whatever the immunity may be, it is evident that it is
not lasting enough or forcible enough, in more than a small
ratio of cases, to make much impression on hereditary trans-
mission. Suppose one hundred people have small-pox ; pos-
sibly out of this number there might be twenty instances
where the immunity would be powerful enough to cause
more or less impression on the forces of heredity.
The two great forces of the development of all organ-
isms are atavism and variability. Development is a result-
ant of these two forces. Behind them both are the most
complex antecedents pertaining to the struggle for exist-
ence ; but these complex antecedents, grouped as they all
are under two heads, all converge into the two forces which
we understand as atavism and variability. The character
of human development, from the mental and moral peculi-
arities to even the color of the skin and the stature of the
man, must be referred to the interactions of these two forces
for a solution, and we must look to these things also for a
solution of the problem of immunity from disease.
From these data there is no better inference than the
hypothesis that an actual attack of pathogenic organisms
produces a variation of structure, the character of the varia-
tion and the structure subject to the variation being deter-
mined by the nature or method of onslaught and the tis-
sues or cells that are attacked. Following up these special
lines, we find that different pathogenic organisms attack
different portions of the body, and that the method of war-
fare is by poisons.
To fortify this hypothesis it may be mentioned that liv-
ing things which are adapted to each other as a food-supply
must kill each other or catch each other first, and I think
the two methods of causing death are by mechanical means
and by poisons. Animals use stratagem, speed, tooth, beak,
claw, muscles, and poisons, while the pathogenic bacteria use
poisons. The micro-organisms, it is supposed, absorb their
diet by osmosis, and it can not be imagined that this force
of absorption can overcome the vital or physical integrity
of a tissue-cell, and therefore the inference is that, if the cell
resists the absorptive force of the micro-organism by its
quality of life, it must resist the poison of the same agent
by a variation of its vital or physical power of resistance,
which is acquired by actual combat.
If the ancestor of the antelope was given an occasional
chase by a personal enemy — for instance, a wolf — and suc-
ceeded in escaping, no one will dispute the fact that the an-
telope obtained its speed by such means, and transmitted
this quality to its progeny. The difference in speed be-
tween the ancestor of the antelope and the modern species is
the measure of the variation produced by actual combat with
a personal enemy. The struggle for existence of this special
character caused this variation. If a whole herd of wolves
should now be turned into an inclosed lot with an antelope,
it is quite likely that the antelope would fall a victim, but
this would not disprove the fact that in a state of nature the
speed of the antelope was developed in this manner, and
that nature, or natural selection, by this means has preserved
the antelope as a species. This bit of biology explains a
special instance of the law of variability. But now, sup-
pose the species of wolf is destroyed ; the force behind this
variation is removed; the antelope has no care to exercise its
speed, and gradually loses its power, and, in time, by what
is called atavism, it again resembles, in this respect, its an-
cestor.
The pathogenic bacteria are organisms of prey, and a
disease is simply a combat between the cells and the organ-
isms which are there after food. It is difficult or impossible
to say how a poison may destroy a cell, but it is certain
that the effect of the poison is to destroy life, and such is
its object. If it is true that disease is thus caused by de-
stroying the life of cells, then it is true that immunity may
be acquired by a variation of the cell in structure or func-
tion, so that it may resist the poison. The question of
drug-tolerance by cells is established by experiments with
morphine, alcohol, etc. There is no scientific method of ex-
plaining this fact except by the inference that a variation in
structure and function is produced in the cell as a conse-
quence of actual combat with the poison. The cell may
secrete an antidote to the poison of the enemy, or its mo-
lecular elements may be rearranged in such a manner that
the poison is not effective. Either of these propositions
may do as an hypothesis, and, though they may be difficult
42
BOOK NOTICES.
[N. Y. Med. Jock.,
to verify, they are true verce causae in nature, and they can
explain the phenomena of the immunity from disease, singly
and collectively.
Suppose, now, the cause of disease is removed ; the cells
which have acquired a variation of structure or function, by
the law of atavism, lose this variation. In time the im-
munity ought to run out, and we find this to be true. The
immunity from, or protection given by, one attack of disease
varies, in time, in direct proportion to the severity of the
disease, as a ride. There is no other method of explaining
this phenomenon except by these laws of variability, ata-
vism, and natural selection.
The artificial tests for the protection thus afforded
against disease, which consist in injecting a large quantity
of pathogenic bacteria into an animal which is sufficiently
protected to resist the attacks of disease by natural inva-
sion, resembles the method mentioned of testing the pro-
tection given the antelope through its speed by exposing it to
a pack of wolves in an inclosure. The conditions of nature
in these instances are not imitated, and, consequently, no in-
formation of value can be inferred from such experiments.
{To be concluded.)
A Practical Treatise on Nasal Catarrh and Allied Diseases. By
Beverley Robinson, A. M., M. D. (Paris), Clinical Professor
of Medicine at the Bellevue Hospital Medical College, etc.
Second Edition, Revised and Enlarged, with One Hundred
and Fifty-two Wood Engravings. New York: William
Wood & Co., 1885. Pp. xii-276.
Those who were so fortunate as to read the first edition of
this excellent work will hardly recognize it in the elegant sec-
ond edition now before us. To the book as it first appeared
five chapters have been added. These are devoted to the
study of: 1. Aural Complications of Catarrhal Affections of the
Nose. 2. Deflections of the Nasal Septum and Bony Obstruc-
tions of the Nasal Passages. 3. Ulcerous Coryza. 4. Adenoid
Vegetations at the Vault of the Pharynx. 5. Mucous Nasal
Polypi.
The text of the original edition has also been carefully re-
vised, and changes or additions made where required, while
ninety-six illustrations have been added, and the work made
complete up to the date of its issue. Want of space forbids the
extensive review which should be given it. There is much in it
which deserves commendation, and every evidence of experi-
ence in the use of the methods advised and of painstaking care
in their presentation.
The main fault of the author is an undue redundancy of
style, which adds unnecessarily to the length of his chapters
without in any wise contributing to their clearness.
Among the cuts the reader will recognize the familiar face
of many an old friend. Figs. 26 and 27 might well have been
omitted.
Compared with the substantial merit of the work, however,
these are trifling matters. It will be difficult to find in any
language a more exhaustive and thorough treatise upon nasal
catarrh, so that the book should, and we believe will, have a
wide circulation
Post- Nasal Catarrh and Diseases of the Nose causing Deafness.
By Edwakd Woakes, M. D., Senior Aural Surgeon and Lec-
turer on Diseases of the Ear, London Hospital, etc. Illus-
trated with Wood Engravings. Philadelphia: P. Blakiston,
Son h Co., 1884. Pp. 224. [Price, $1.50.]
This is an American reprint from the third English edition.
The first chapter is devoted to some observations on the cor-
relating and reflex functions of the sympathetic nervous sys-
tem. Then follow two chapters on the vEtiology of Acute and
Chronic Catarrh, in which are considered what Woakes calls the
" pre-catarrhal state," and the mechanism of "taking cold."
The chapter on the Hygienic Management of the " Catarrhally
Predisposed" is full of useful hints and suggestions. The diffi-
culties and importance of posterior rhinoscopy are well em-
phasized, and a most excellent account is given of the method
of anterior rhinoscopy. There have been so many additions
made to the original work that the English publishers thought
it wise to issue the new matter in a volume by itself, and this
is what is presented to the medical profession. It is a most
clear and valuable contribution to our hitherto rather defective
knowledge of diseases of the naso-pharynx. Some of the au-
thor's views will certainly not be accepted without careful con-
sideration and repeated observations; but those on therapeutics
will meet with cordial commendation.
A IIand-boo~k of the Diseases of the Eye and their Treatment.
By Henky R. Swanzy, A. M., M. B., F. R. C. S. I., Surgeon
to the National Eye and Ear Infirmary, etc. With Illustra-
tions. New York: D. Appleton & Co., 1884. Pp. xv-437.
Mr. Swanzy has here given to the medical student and gen-
eral practitioner a most admirable hand-book upon what is per-
haps the most important and extensive of the special depart-
ments of medicine. The author, who, as a former assistant to
von Graefe, has been brought up in an admirable school and
whose experience has been very large, treats his subject in a
very thorough manner, while the style is readable and clear.
There is a minuteness of detail in regard to treatment which
will prove especially attractive to the student. The book con-
sists of twenty-two chapters, the first three of which are de-
voted to elementary optics, anomalies of refraction and accom-
modation, and the theory and use of the ophthalmoscope. Under
the latter head there is a full and excellent account of the
method of determining the refraction by the ophthalmoscope
known as " retinoscopy," now much employed in England. A
special chapter is devoted to a consideration of the motions of
the pupil in health and disease, which is a concise and admira-
ble discussion of a subject of great importance to the general
practitioner as well as to the ophthalmologist. Under this head
we find both irritation- and paralytic-myosis, and irritation- and
paralytic-mydriasis. This is prefaced by a consideration of the
size of the pupil in health, and of the action of mydriatics and
myotics on the pupil. A new feature in ophthalmic literature
is to be found in the insertion upon the inner side of the cover
of a set of Holmgren's wool-tests for the detection of color-
blindness. The book is extremely well printed with clean,
sharp type on tinted paper, and the illustrations are excellent.
As a specimen of the book-maker's art, it is admirable.
A Hand-book of Ophthalmic Science and Practice. By Henry
E. J tiler, F. R. C. S., Junior Ophthalmic Surgeon to St.
Mary's Hospital, etc. With One Hundred and Twenty-five
Illustrations. Philadelphia : Henry C. Lea's Son and Co.,
1884. Pp. 467.
Of the making of books on ophthalmic science there seems
to be no end ; but very little fault will be found by any one
July 11, 1885.]
BOOK NOTICES.
43
with Mr. Juler's contribution to the library of opbthalmological
text-books. It is a handsomely printed volume of about four
hundred and fifty pages, well illustrated by plain and colored
drawings and numerous colored lithographs of the fundus of
the eye in health and disease. Some of the plates represent-
ing pathological processes in the cornea, iris, and ciliary body
are particularly good. The book consists of sixteen chapters,
to the arrangement of which in their order of sequence some
exception may be taken. There seems no very good reason
why the crystalline lens, the vitreous humor, and glaucoma
should be considered after the subject of color-vision and its
defects, nor why the chapter on Diseases of the Orbit should be
placed last. It is much to be regretted that in the chapter on
Conjunctival Diseases the author does not clearly distinguish
between membranous and diphtheritic conjunctivitis, instead of
classing them under the same head. They are two distinct dis-
eases, and should not by any means be confounded. It may be
said that ophthalmic surgeons, at least on this side of the At-
lantic, are almost unanimous upon this subject. Due promi-
nence is given to Mr. Wolfe's operation by transportation of a
flap without pedicle for correcting certain cases of ectropium,
or lid defect. The chapters on the Visual Field, Color-vision,
and Color-blindness, Anomalies of Refraction and Accommoda-
tion, and the Ophthalmoscope are good, but it is necessary to
state that they are all written from the English standpoint,
which differs in some respects decidedly from that prevailing in
this country. The pathological work is mainly represented by
the colored drawings, there being very little in the text. The
importance of the ophthalmoscope as a means of measuring
the refraction is well stated, and there is a very good descrip-
tion of the method known as retinoscopy, or the shadow test,
which, however, can be employed only by the practiced expert.
In the chapter on Diseases of the Muscles the author prefers
Anderson Critchett's operation for advancement of a muscle.
Notes on Operations on the Eye. By Ram Kishen, L. M. S.,
Lahore, Assistant Surgeon. Lahore: Printed at the "Tri-
bune" Press, 1884. Pp. 2-ii-78-iii.
This little duodecimo volume of about eighty pages is by a
native of the Punjab, and, as the author says in the preface, is
an attempt to draw attention to the practical points in connec-
tion with the principal operations in ophthalmic surgery. There
are no illustrations, and the English is awkward and at times
verging on the ludicrous. The operations are, however, suffi-
ciently well described.
A Guide to the Diseases of Children. By James Frederick
Goodhart, M. D., F. R. C. P., Assistant Physician to Guy's
Hospital, and Lecturer on Pathology in its Medical School,
etc. Revised and edited by Louis Starr, M. D., Clinical
Professor of Diseases of Children in the Hospital of the Uni-
versity of Pennsylvania, etc. Philadelphia : P. Blakiston,
Son & Co., 1885. Pp. 738. [Price, cloth, $3; sheep, $4.]
The special design of this book, the author tells us in his
preface, is to furnish to medical students a manual for ready use
in this department. A careful examination of the book will
convince any one of the fact that he has succeeded admirably.
We predict that its use will not be limited to students, but that
the practitioner will find it convenient, trustworthy, and ex-
tremely suggestive upon most of the practical questions which
it discusses. It is pre-eminently a book written out of the au-
thor's personal experience. Every page bears witness to the
fact that he has been a wide and careful observer. The book is
written in a readable, forcible style, and the points are clearly
stated. The author possesses the rare faculty of condensing
minor details and bringing out salient points vividly. Being at
the same time a teacher in pathology, he has not neglected that
branch of his subject, although the size of the work has made
it necessary to condense very much.
When there is so much to praise, it is not easy to say which
parts of the book are the most valuable. The articles on whoop-
ing-cough, empyema, scarlatina, and diphtheria are especially
good. The author holds that the last-mentioned is distinct from
membranous croup, but states that this distinction must rest on
clinical and not on histological grounds. His treatment of em-
pyema is by early evacuation, preferably by incision, although
he says other means may be tried in some cases. He reports
twenty-six cases treated consecutively, with but a single death.
We can not quite agree with him that there is no advantage in
distinguishing between the two forms of acute pneumonia.
There are many minor matters in which the book might be
improved, but its excellences are so many that they can be
overlooked. On the whole, we consider the work one of the
best of its kind that have appeared in a long time. It will un-
doubtedly demonstrate its right to existence.
The work of the American editor has been fairly done, but
we should have been quite as well pleased with the book in its
original form. He has avoided the error of too extensive addi-
tions. In the translation of the expressions of the British Phar-
macopoeia into those of the United States Pharmacopoeia he has
rendered a real service.
The Theory and Practice of Medicine. By Frederick T. Rob-
erts, M. D., etc., Professor of Materia Medica and Therapeu-
tics, and of Clinical Medicine, at University College, etc.
With illustrations. Fifth American Edition. Philadelphia :
P. Blakiston, Son & Co., 1884. Pp. 1008.
Dr. Roberts's book is sufficiently well known to need but
little reference to it. This is the fifth edition — an evidence in
itself of its favorable reception by the profession. It is the
text-book used in many of the medical schools in this country.
S:nce the last edition the author has revised his work
throughout, and has incorporated the results of discussions
which have taken place since the appearance of the last edition
in so far as they seemed of practical importance. He has paid
special attention to diseases of the nervous system in this edi-
tion.
He discusses Koch's theories on the Bacillus tuberculosis,
and gives a plate of illustrations of the bacillus. He does not
commit himself to a positive opinion, but closes his discussion
of this subject with the following significant remark : " It would
be premature at present to come to any positive general con-
clusion on the subject ; but there seems to be no doubt as to
the possibility of tuberculosis being developed by infection from
within and from without under certain circumstances." The
discussion on the cholera bacillus had not taken place at the
time this edition was issued. The author has here, as in pre-
vious editions, included skin diseases, which seems odd, at least
to physicians in this country.
The work is an admirable one, and fully deserves the excel-
lent reputation it has gained both as a text-book and as a safe
and reliable book for the practitioner.
BOOKS AND PAMPHLETS RECEIVED.
Bacterial Pathology. A Series of Papers on the Exhibits
at the Biological Laboratory of the Health Exhibition. Under
the Charge of Watson Cheyne. Reprinted from the " Lancet."
New York : The Industrial Publication Co., 1885. [Price, 25 c.]
Report of the New York Hospital Saturday and Sunday
Collection of 1884.
Introductory. Fifth Annual Report of the [? New York]
State Board of Health.
LEADING ARTICLES.
[N. Y. Med. Joub.,
the
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by
D. Appleton & Co.
Edited by
Prank P. Poster, M. D.
NEW YORK, SATURDAY, JULY 11, 1885.
THE RUMP CONGRESS OF 1887.
It was scarcely to be expected that those eminent physi-
cians of Philadelphia whose action in regard to the organization
of the Ninth International Medical Congress we recorded last
week would find themselves alone in the resolve to stand aloof
from a gathering which, as is constantly growing more and
more manifest, will be an international congress only in name.
As will be seen by our news columns, Boston and Baltimore
have promptly followed suit, and, like the Philadelphia resolu-
tions, those passed in Boston and Baltimore are signed by men
whose names are indissolubly connected with American medi-
cine. Whether organized action of like significance will be
taken in New York and elsewhere, it is impossible to say, but
this much is certain, that some of the New York men whom
the new committee of the American Medical Association placed
among the officers of sections have no sympathy with the os-
tensible motives— far less with the real motives— which led a
little band of malcontents to plot the destruction of the Wash-
ington meeting. Even if those gentlemen do not formally ex-
press their feelings in the matter, there can be no doubt that
they will abstain from any participation in the Washington
meeting.
It looks, indeed, very much as if the part of Hamlet would
be left out at Washington in 1887, for our foreign colleagues
will in all probability decide not to cross the Atlantic in any
great numbers for the pleasure of meeting the rump of the
American profession. And all this disgrace is the logical out-
come of the false and artificial issues which for the past three
years have enabled men in no way representative of the profes-
sion to masquerade as its leaders, through the medium of that
degenerate and utterly ridiculous concern the American Medi-
cal Association. That organization long ago ceased to work for
the benefit of the profession, and for a number of years past its
annual meetings have been little more than scenes of the most
shameless intrigue and demagogism. From the nature of its
make-up, and from the character of the men who manipulate it
year after year, the hope is exceedingly untenable that, within
any reasonable period, this state of things will be mended. It
has made itself as odious as any board of aldermen in the land,
but, unfortunately, it is so intrenched in jugglery that to draw
its fangs is almost as unpromising a task as that of uprooting
municipal misgovernment. Difficult as this task is, however, its
accomplishment is only a question of time, and it is even now
evident that, for at least five years past, the association has
owed its continued semblance of life to the force of the familiar
politicians' plea that, whatever its shortcomings might be, it
was, after all, the only organization of a national character that
professed to be in any way representative of the whole profes-
sion. If its hangers-on think that its steady degradation is for
ever to be condoned on the strength of this plea, we would
point them to what lately happened to one of the great politi-
cal parties of the country. The plea amounts to this, that any-
thing which the American Medical Association chooses to do ia
better than no concerted action at all. How long this specious
cry is likely to prove potent may be judged of from the fate
which, in the history of the world, has uniformly overtaken
organized villainy sooner or later, no matter what its seeming
power, and no matter how white its hypocritical cloak.
The crowning act of infamy in the downward career of the
American Medical Association has been achieved in the wreck-
ing of the American meeting of the International Medical Con-
gress, a meeting which, but a year before, it had seemed to be
doing its best to make creditable and successful. Doubtless it
may be said with truth that the action it took at New Orleans
is not in consonance with the deliberate convictioos of the
great mass of its members, but that consideration is in fact a
most telling arraignment of its methods of dealing, for an or-
ganization which fails year after year to bring out the real
sentiments of its members falls conspicuously short of the aims
it ostensibly has at heart.
That the wreck of the Congress of 1887 has not been irre-
trievably wrought we can now see no reason to hope. It is, of
course, not to be supposed that the Congress will formally
reconsider its acceptance of the invitation extended to it by the
American profession, but the conclusion can scarcely be avoided,
nevertheless, that the European members who would add luster
to the gathering will individually make up their minds not to
attend the meeting, and it will simply go by default.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Health Department for the following
statement of cases and deaths reported during the two weeks
ending July 7, 1885 :
DISEASES.
Week ending J une 30.
Week ending July 7
Cases.
Deaths.
Cases.
Deaths.
13
4
13
4
29
7
35
5
Cerebro-spinal meningitis. . . .
1
1
4
4
100
25
56
12
63
35
41
21
0
0
3.
0
Yellow Fever. — A single case was reported to the New
Orleans Board of Health by a physician last Saturday, and two
inspectors confirmed his diagnosis. The patient was convales-
cent at the time, and we have no information of the spread of
the disease.
Small-pox. — An Astoria physician encountered a case of
small-pox at Hunter's Point last week, and at once notified the
sanitary officials of Long Island City, who, however, seem to
have been in no haste to adopt measures for the protection of
the community. Early this week a case was discovered in New
York, in the upper part of Fourth Avenue. The patient, a
child, was removed to the Riverside Hospital.
July 11, 1885.]
MINOR PARAGRAPHS.
45
The International Medical Congress and the Medical
Profession of Boston.— At a meeting held in the Medical Li-
brary Building, in Boston, on July 2, 1885, the following reso-
lutions were unanimously adopted :
Whereas, We had been led to believe that the authority to
organize and control the Ninth International Medical Congress
had been permanently delegated by the American Medical Asso-
ciation to its original committee, thus providing against any
radical changes in its published programme; and
Whereas, The American Medical Association has revised the
action and annulled appointments of that committee in a way
which we regard as detrimental to the interests of the medical
profession of America and fatal to the success of the Congress ;
therefore be it
Resolved, That we, the undersigned, members of the medical
profession in Boston and vicinity, concerned in the organization
of the Ninth International Medical Congress, decline to hold
any office in said Congress as now organized.
Robekt Amory,
G. M. Garland,
IT. P. Bowditch,
R. T. Edes,
J. J. Putnam,
Franois Minot,
J. R. Chadwick,
C. F. Folsom,
Hasket Derby,
S. G. Webber,
T. M. RoTcn,
T. FlLLEBROWN,
R. H. Fitz,
Thomas Dwight,
C. J. Blake,
J. C. Warren,
O. F. Wadsworth,
S. J. Mixter,
F. I. Knight,
G. H. Lyman,
Jacob L. Williams,
H. W. Williams,
H. P. Walcott,
J. Orne Green,
E. Wiggles worth.
The International Medical Congress and the Medical
Profession of Baltimore. — In consequence of the dissatisfac-
tion caused by the recent action of the new Committee on the
Organization of the Ninth International Medical Congress, the
subjoined paper has been signed by those whose names are ap-
pended.
Whereas, The new Committee on the Organization of the
Ninth International Medical Congress, at its recent meeting,
held in Chicago, made such changes in the arrangements for the
Congress as, in our opinion, will mar its success, and will prove
injurious to the interests of the medical profession, it is there-
fore
Resolved, That we, the undersigned, disapprove of the action
of the committee, and decline to accept the positions to which
we have been appointed under it :
I. E. Atkinson,
S. C. Chew,
Julian J. Chisolm,
Christopher Johnston,
William Lee,
John N. Mackenzie,
Richard McSherry,
F. T. Miles,
Alan P. Smith,
Samuel Theobald,
L. McLane Tiffany,
H. P. C. Wilson.
The New York Post-Graduate Medical School and Hos-
pital.— Dr. Horace T. Hanks has been elected professor of dis-
eases of women, and Dr. Lewis S. Pilcher professor of clinical
surgery.
The New York Polyclinic. —The "Journal of Comparative
Medicine and Surgery " announces that the faculty of the Poly-
clinic, of which Dr. Frank S. Billings is a member, has consented
to his teaching special classes of veterinarians in the pathologi-
cal laboratory of the institution.
The Water Supply of Manhattan Beach having been made
the subject of complaint, the local health officer, Dr. R. L. Van
Kleek, has caused an examination of the water to be made, and
reports that it is of good quality.
The New Hospital for Infectious Diseases, on North
Brother Island, is nearly ready for occupation, and it is expected
that the Riverside Hospital will soon be abandoned.
Cremation in Buffalo. — It is announced that a crematory
is soon to be built near the cemetery in Buffalo, the incinerating
apparatus for which is to be made in Milan, Italy.
The Glasgow Obstetrical and Gynaecological Society.—
Our English exchanges announce the organization of a society
with this title in Glasgow, with Professor Leishman for presi-
dent.
The Royal Academy of Medicine, of Rome, according to
the "Lancet," has admitted the British delegates to the recent
International Sanitary Conference, Sir Guyer Hunter, Dr. Thorne
Thome, Sir Joseph Fayrer, and Dr. T. Lewis, as honorary fel-
lows.
The Death of Dr. Joseph Estabrook, of Rockland, Me.,
took place last Sunday. The deceased was eighty-seven years
of age, and is said to have been the oldest graduate of Williams
College at the time of his death. He was an alumnus of the
Harvard Medical School. Many years ago he was the demon-
strator of anatomy in the Medical School of Maine, and had been
president of the Maine Medical Association.
The Death of Dr. G. B. Soresina, the distinguished Italian
syphilidologist, is announced in the " Gazzetta degli Ospitali."
The deceased was eighty-three years of age.
Army Intelligence.— Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from June 28, 1885, to July 3, 1885:
Ainsworth, F. C.j Captain and Assistant Surgeon. Relieved
from duty at Headquarters Department of the Missouri. S.
0. 93, Department of the Missouri, June 26, 1885.
Taylor, B. D., Captain and Assistant Surgeon. Assigned to
duty at Little Rock Barracks, Arkansas. S. 0. 139, Depart-
ment of the East, July 1, 1885.
Naval Intelligence.— Official List of Changes in the Medi-
cal Corps of the United States Navy during the two weeks end-
ing July If, 1885.
Bransford, John F. Commissioned as surgeon on active list.
June 16, 1885.
Ross, J. W., Surgeon. Detached from Naval Laboratory, and
waiting orders. June 30, 1885.
Shafer, Joseph, Assistant Surgeon. For duty on board the
U. S. Receiving Ship St. Louis, League Island, Pa. July 10,
1885.
Society Meetings for the Coming Week :
Monday, July 13th: Boston Society for Medical Improvement;
Gynjecological Society of Boston ; Burlington, Vt., Medical
and Surgical Club; Norwalk, Conn., Medical Society (pri-
vate).
Tuesday, July Uth : Medical Societies of the Counties of Clin-
ton (Plattsburg), Jefferson (Watertown), Madison, Oneida
(Utica), Ontario (Canandaigua), Rensselaer, Schuyler, Tioga
(Owego), and Wayne, N. Y. ; Norfolk District, Mass., Medi-
cal Society (Hyde Park).
Wednesday, July 15th : New Jersey Academy of Medicine
(Newark).
Thursday, July 16th : New Bedford, Mass., Society for Medi-
cal Improvement (private).
46
LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Joitb.,
fetters to t|je debitor.
THE MEDICAL PROFESSION IN CINCINNATI.
Cincinnati, July 3, 1885.
To the Editor of the New York Medical Journal:
Sir: In your issue of May 30, 1885, page 608, appears a
" Letter from Cincinnati," upon which I ask permission to make
comment. Some of its statements are unjust to the medical
societies and profession of Cincinnati. For the sake of brevity,
I condense some paragraphs from the letter and place them
in relation without special regard to their order in the letter.
" About ten years ago Dr. Reamy, then a new comer, made
the declaration in debate in the Academy to the effect that there
were members of the Academy, in otherwise good standing, who
were guilty of criminal abortion. . . .
" Dr. R. was a member of the faculty of the Medical College
of Ohio ; his immediate antagonists were of the faculty of the
Miami Medical College. The third party, the Cincinnati Col-
lege of Medicine and Surgery, kept its hands off and watched the
fun." . . . The vote came. Dr. R. was vindicated. " The Mi-
ami people said, No man can maintain his self-respect and re-
main a member of the Academy. They resigned and organized
the Cincinnati Medical Society." . . . The feelings then engen-
dered have succeeded in keeping many people from both the
Academy and the Cincinnati Medical Society, for in that way
alone was it possible to maintain friendship with both factions.
The result has been a dearth of good matter presented at both
societies, . . . •' the generally meager attendance at the meet-
ings particularly of the Academy and the Cincinnati Medical
Society." . . . "The fact is that either animosity or apathy in-
terferes with the popularity of both these societies." . . .
Comment. — 1. Dr. Rearay's charge was in these words:
" For we must not shut our eyes to the fact, known to us all,
that there are members of the medical profession, in otherwise
good standing, who sometimes commit abortions." The Acade-
my of Medicine was not mentioned by the speaker.
2. Neither the gentlemen who introduced the resolution ar-
raigning Dr. R. for his utterances, nor either of the three gen-
tlemen composing the committee on ethics conducting the prose-
cution, were members of, or in any way connected with, the
faculty of the Miami Medical College, nor have they since been
so connected.
3. One of the most active members of that committee was
for some time an able lecturer in the Cincinnati College of
Medicine and Surgery. And the present professor of surgery
in this same college was one of Dr. R.'s most earnest support-
ers during the controversy referred to. And one of the spiciest
letters of the many received by Dr. R. during that controversy
was written by the father of your Cincinnati correspondent,
who was at that time one of the oldest and most active mem-
bers of the Cincinnati College of Medicine and Surgery.
4. Though a new society was organized, and though many
of those who participated in its organization had recently re-
signed from the Academy, there were many, and are now many,
who are members of both societies.
5. The membership of the Academy is as large as before the
organization of the new society. The average attendance at
stated meetings is as great, the papers read, cases reported, and
discussions thereof are as able, interesting, and instructive as at
any period in its history. An examination of its recorded pro-
ceedings will prove the truth of this assertion. Many of the
papers and discussions will compare favorably with the work of
any similar society in the country.
6. Though the attendance at the meetings of the Cincinnati
Medical Society is not quite so large as that of the Academy, as
the membership is not so large, yet the attendance is good, and
their papers and discussions merit the same commendation as
above given to the Academy. Both of the societies are popular.
Of neither can it be said that "there has been a dearth of good
matter presented."
7. There is no bitter feeling held against the other by either
of these societies. Nor is there any hatred between individual
members thereof. Nor between the faculties of the Medical
College of Ohio and the Miami Medical College.
8. The statement that "the active participants in the old
fight are gradually retiring from the field of active practice, and
are, fortunately, quite unable to leave their hatreds as a heritage
to the new generation," demands the following reply: Two or
three of the participants in the old fight have died. Of those
remaining, every one is in active practice, some of them doing
six times more professional work now than then. As to
hatreds, they have none. Personal and professional friendships
prevail between the leaders on both sides. It is true the fight
was "acrimonious," but, as no personal issues were involved —
only misunderstandings as to the application intended by Dr.
R. in bis original statement made in the Academy — it was quite
natural that, after all was over, friendship should be restored ;
and it was. All this occurred without an apology or explana-
tion being made by the former antagonists in any instance. The
absolute obliteration of ill-feeling which has for years existed
may be considered exceptional, and is certainly commendable
to all parties.
It is the testimony of those who know best, that friendship,
harmony, and good feeling never prevailed more supremely in
the medical profession of Cincinnati than at present.
The impressions sought to be made by the letter of your
correspondent are therefore unwarrantable, and demand con-
tradiction.
But what prompted him ? His intelligence is well known ;
that he wrote in malice toward any is not at all probable. That
he would write what he knew to be untrue I do not believe.
What then?
Residing and practicing in another town, he can not attend
the meetings of the societies in Cincinnati nor mingle with the
profession, and has therefore been misled as to his facts.
Very respectfully,
Tbad. A. Reamy.
fJroteebings of Soriet'us.
NEW YORK PATHOLOGICAL SOCIETY.
Meeting of May 27, 1885.
The President, Dr. John A. Wyeth, in the Chair.
Epithelioma of the Tongue. — Dr. 0. W. Knight presented
a portion of the posterior part of the tongue, the seat of epi-
thelioma, removed after ligation of the lingual artery.
Lipoma of the Back. — Dr. L. Waldsteix presented the speci-
men, removed by Dr. Lange from a woman eighty-six years of
age. The tumor was removed because of the presence of an
ulcer of the skin which refused to heal. The specimen illus-
trated the fact that lipomas sometimes developed and did not
become reduced in size in persons in whom there was marked
emaciation.
Adeno-sarcoma of the Stomach. — Dr. Waldstein pre-
sented a second specimen of adeno-sarcoma of the stomach, of
July 11, 1885.]
PROCEEDINGS OF SOCIETIES.
47
the diffuse variety, located chiefly at the fundus and cardiac
extremity. The patient, forty-six years of age, had suffered
extremely during the last four months of life. There were large
quantities of granular detritus from division of the nuclei which
had sometimes heen mistaken for micro-organisms. There had
been marked jaundice, and a diagnosis of carcinoma of the liver
was made, a tumor of the size of a pigeon's egg being mistaken
for that disease. The autopsy showed the tumor to be the en-
larged gall-bladder, the duct of which was partially obstructed
by metastatic tumors of the lymphatic glands of the porta
hepatis.
Diphtheritic Laryngitis. — Dr. Joseph E. Winters pre-
sented the lungs of a child nearly two years of age, which had
died of exhaustion and asphyxia due to diphtheritic laryngitis.
The disease had for some days been limited to the fauces, not
involving the larynx for more than a week. When dyspnoea
was present tracheotomy was proposed, but rejected by the
father. The autopsy showed the presence of the exudate only
for three fourths of an inch below the vocal bands. There were
muco-pus and vascularization below that point. There was
marked vascularization at the bases of the lungs, and in the
anterior portion there was some degree of anaamia with unusual
distension.
Dr. C. C. Lee asked Dr. Winters what had been his experi-
ence with Dr. O'Dwyer's laryngeal tube.
Dr. Winters said that, the tubes having been so generally
discarded in France, he had not employed them.
Dr. Lee remarked that the tubes used in this city had ar-
rested the progress of spasmodic disease and had saved lives
where laryngotomy doubtless would have failed. He thought
the tube might prove useful in cases of diphtheritic laryngitis
by relieving dyspnoea when the parents would not consent to
tracheotomy.
Dr. Northrup remarked that at the New York Foundling-
Asylum the tube had relieved urgent laryngeal symptoms almost
immediately. He asked Dr. Winters whether in his experience
the past season the false membrane had shown a strong tendency
to extend downward into the bronohi.
Dr. Winters said that most of the cases which he had seen
were consultation cases, and he thought that when treated early
the membrane had not extended much below the larynx. He
thought the tendency of the exudate to spread would be greater
in institutions than in private practice.
Dr. H. J. Boldt said that, according to his experience dur-
ing the past winter, the false membrane had shown a great
tendency to extend below the larynx.
Dr. J. C. Peters had employed frequent irrigation of the
throat and used bichloride of mercury in cases of false mem-
brane upon the top of the larynx, and the patients recovered
without extension of the membrane downward.
Pott's Disease ; Necrosis of all the Principal Long Bones.
— Dr. W. P. Watson, of Jersey City, presented the specimens,
consisting of certain vertebra}, removed from the body of a
child five years of age, which had died of pneumonia. The
child had first developed a swelling over the right thigh, which
was said to have entirely disappeared. Afterward there was
curvature of the spine in the cervico-dorsal region, reaching a
right angle, but at no time was there paralysis. Abscesses also
developed over the thigh and both wrists, and exsection of a
considerable portion of the right radius and of the right knee
joint and lower portion of the femur was performed. At the
autopsy there was found to bo marked absorption of the fifth,
sixth, and seventh cervical, and of the first and second dorsal,
vertebras. It was remarkable that but very little compression
of the cord had taken place.
Frequent Recurrence of Pregnancy.— Dr. Watson also
presented a foetus of the sixth week which was aborted a few
days after the repair of a bilateral laceration of the cervix
uteri. The patient was an English woman of robust health,
who had been pregnant seven times in six years, three being
single and four twin pregnancies. Only two of the pregnancies
went to full term. Menstruation had occurred less than a
month before the cervix was repaired, and there was no reason
to suspect pregnancy.
Multilocular Cystoma of the Right Ovary with Hydro-
salpinx, and Cystic Degeneration of the Left Ovary with
Simple Salpingitis.— Dr. R. W. Wilcox presented the speci-
mens removed from a patient thirty-seven years of age, married,
never pregnant. The enlargement of the abdomen had been
observed for fifteen years, and during the last two years had
been so great as to interfere considerably with locomotion. The
patient was first seen by Dr. Wilcox in February las-t, when she
was suffering from peritonitis pretty generally distributed, and
from acute nephritis due to diuretics administered by her physi-
cian, who supposed her to be suffering from abdominal dropsy.
There was no difficulty in making a diagnosis of tumor of the
ovary. The nephritis subsided, and the peritonitis resulted in
adhesions. Dr. Thomas performed ovariotomy. The larger
tumor weighed a little more than forty-five pounds ; the others
were small. The tube was adherent to the tumor, elongated
and atrophied, the uterine extremity occluded ; there was dis-
tension with a clear yellow fluid. The left ovary had also
undergone cystic degeneration, and the tube was adherent to it.
Thrombosis of the Left Coronary Artery ; Interstitial
Myocarditis and Dilatation of the Heart.— Dr. J. F. Ridlon
presented the heart, very much enlarged, with thrombosis of
the left coronary artery, of a man about fifty-five years of age,
who had for some years suffered from dyspeptic symptoms with
an interval of apparent good health extending over some
months. About noon, April 30th, having been in his usual
health, he felt distress in the stomach, and soon afterward be-
came faint and vomited. He was seen by several physicians
during the course of the afternoon and night, and at one time
was supposed to be dead, but revived. The pain and restless-
ness were finally checked by a small hypodermic injection of
Magendie's solution of morphine. The patient was able to walk
to the fixed basin, which he insisted upon doing when com-
pelled to vomit. At 7 a. m., May 1st, he seemed to be much
better, but was found dead half an hour later. The most im-
portant lesions found post mortem were, as stated, thrombosis
of the left coronary artery, completely obstructing its caliber,
marked enlargement of the heart with dilatation, interstitial
myocarditis, and fatty degeneration; there was also enlarge-
ment of the liver, spleen, and kidneys. The stomach appeared
normal, but contained a few ounces of blood.
Intra-meningeal Haemorrhage.— Dr. W. P. NoRTrmnp
presented a microscopical slide, illustrating this condition. He
also presented a
Section of a Lung embedded in Celloidin.— After find-
ing that the ordinary processes were inadequate for the prepa-
ration of the entire lung for section, he placed the lung in a
weak mixture of alcohol and water for some days, afterward in
celloidin for a number of days, and finally again in alcohol. By
this process he was enabled to make a complete section of the
base of the lung. The section presented showed interstitial em-
physema and in places pneumonic consolidation and infiltrated
and dilated bronchi.
Multiple Abdominal Tumor.— Dr. C. C. Lee presented the
specimen, removed from a quadroon, twenty-six years of age,
of delicate frame, emaciated, who had observed an enlargement
of the abdomen said by several physicians who had seen her
not to be due to pregnancy. Dr. Lee diagnosticated tumor of
48
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jouh.,
the ovary, although he had never seen a pure ovarian cyst in
the negro race. At the operation the growth was found to in-
volve the uterus, which was also removed. The tumor had
probably begun as a tibro-cyst of the uterus which had under-
gone colloid and partial cystic degeneration. At one point were
found a few hairs and a slight osseous formation. The patient
had shown no bad symptoms since the operation.
Exsection of the Hip Joint.— Dr. L. H. Sayke presented
the remains of the necrosed upper portion of the femur and
detritus of the acetabulum removed by exsection in the case of
a girl eight years of age, who had for some years suffered from
hip disease. The trouble began with pain in the knee. Differ-
ent forms of apparatus had been applied by physicians in Illi-
nois, Missouri, and Kansas, and with varying degrees of success
so far as relief from the symptoms was concerned. There was
a phthisical history in the family, and this child was born pre-
maturely between the seventh and eighth months. The opera-
tion of exsection was done by Dr. Sayre the present month, and
the child was doiDg well.
MEDICAL SOCIETY OF THE COUNTY OF KINGS.
Meeting of May 19, 1885.
The President, Dr. J. A. MoCorkle, in the Chair ;
Dr. Z. T. Emery, Secretary.
Cholera Asiatica and Cholera Nostras ; their Diagnosis
and Treatment, with Special Reference to the Bacillus.—
Dr. Arnold Stub read a paper with this title. [See page 32.]
Dr. Chase remarked that the author had stated that raising
water to a high temperature would destroy cholera bacilli.
Would the cooking of fruit, particularly apples, have the same
effect ?
Dr. Stub replied that he thought it certainly would, provid-
ed that after the apples had been cooked they were not allowed
to stand exposed.
Dr. L. Barkan said that, having been deputed by the Aus-
tro-Hungarian Government to treat cholera patients, he had
had some experience with the disease. He had seen no benefit
result from the use of opiates, but had had excellent success
with sulphate of quinine. From a theoretical standpoint, he
would oppose the use of hot baths, because the increase of tem-
perature might be followed by a marked decrease, in accord-
ance with Traube's theory.
Dr. W. H. Thayer remarked that the paper covered so much
ground that he was neither able nor inclined to examine it critic-
ally throughout. One or two points, however, in the treatment
of cholera appeared to him to be worthy of notice. He could
not agree with Dr. Stub in his statement as to the effect of hot
baths in the algid state of cholera. It was the experience of
many physicians in several epidemics that the use of the hot
bath was injurious and fatal to the patient. Dr. Parkes, an
East Indian surgeon, who had published a very admirable re-
port on cholera, after five years' experience in India, said pa-
tients to whom a warm bath was given invariably came out of
it colder than when they went in, and the disease was more
rapidly fatal than if the bath had not been given. The speaker
was confident that this had been the experience of physicians in
other parts of the world, and it had been his experience in the
epidemics of 1849 and 1866. A similar statement was made in
the report of the Boston Cholera Hospital, in which, in 1849,
they treated two hundred and fifty patients. Cold water had
not only been more grateful to the patient, but it had had no
unpleasant effects. Another point he wished to speak of was
the use of opium, which Dr. Stub had advocated. In the speak-
er's experience, and that of all others who had seen much of
cholera, it had been found to be wholly inert after the establish-
ment of the algid stage. Jt was universally employed in the
management of the premonitory diarrhoea, and with great ad-
vantage; but it must not hence be inferred that it was applica-
ble to the algid stage. It was possible that its inefficacy was
due to the failure of the stomach to absorh it, and that adminis-
tered hypodermically, as Dr. Stub had recommended, it would
have a favorable effect — but that was hypothetical.
Dr. Stub replied that he had not mentioned opium in con-
nection with any stages of the disease except as given hypoder-
mically and in the algid stage, in combination with atropine.
Opium internally would be of no use in any other form. With
the exception of calomel, he would give no remedy by the
mouth. As regarded the question of hot baths, he was not in
the position to deny the statements of Dr. Thayer, in former
epidemics, but he was of the opinion that, had he not given hot
baths to the gentleman connected with the transatlantic steam-
ship company, he would have died. The circulation was very
low, and he could feel only the carotids. The radial pulse had
ceased beating altogether. The baths instilled new life into
him. The pulse became stronger, and he rallied. The speaker
had. not the least doubt that the experience at Boston, as men-
tioned by Dr. Thayer, was correct. He was aware and believed
that different epidemics of cholera had different features. One
epidemic could be managed by certain remedies, while another
epidemic required different remedies. So it might be in the
instances mentioned. He had had the same experience with
yellow fever. In one epidemic a certain course of treatment
would prove very efficient, but would fail, perhaps, in the next.
Dr. R. G. Eooles stated that in some late investigations into
the literature of disinfectants he had come across an analysis of the
results of treatment as compared with non-treatment in a number
of cholera outbreaks. Of the patients under medical care, fifty
per cent, survived, and, of those left entirely alone, fifty per
cent, survived. Among the numerous remedies recommended,
the best results had been reported as coining from aqueous solu-
tions of glycerite of tannin, injected as far as possible up into
the bowels. One French physician had reported extraordinary
success in using this remedy. It was less likely to produce in-
jury than any other. The tannin was decomposed into glucose
in the system, so that its products were harmless. It was alleged
for this remedy that it destroyed the comma bacilli wherever it
came in contact with them, and, by reducing their numbers,
necessarily reduced the quantity of poison to which the danger-
ous symptoms of the disease were due. If treatment had given
no better results than non-treatment in the past, and this qr
any other remedy could save a larger percentage, it would be a
blessing to the race. The reader of the paper had said he could
see no reason for expecting benefit from inoculation in cholera,
since the disease was primarily local. The speaker thought
that on a priori grounds the experiments were not only justi-
fiable, but commendatory. While the comma bacilli were prob-
ably primarily responsible for the disease, all the evil symptoms
resulted from absorption into the blood of the ptomaines pro-
duced by the micro-organisms. Persons who survived an attack
did so because they could resist the paralyzing effects of these
toxic agents. Inoculation, perhaps, accustomed the system to
these poisons, thus establishing a tolerance like that of the mor-
phine and alcohol habits. Such tolerance might constitute im-
munity by giving the cells of the body an advantage over their
foes, so that the germs could gain no habitat, and would fail to
multiply. On the question of disinfectants he thought the
essayist must have meant that chloride of calcium was almost
useless, and not chloride of lime. The latest investigations had
shown that good chloride of lime ranked next to corrosive sub-
limate, both in cheapness and in value as a disinfectant. For
July 11, 1885.J
PROCEEDINGS OF SOCIETIES.
49
some purposes it was superior to everything else. It not only
destroyed the comma bacilli, but quickly and effectually rid us
of the most persistent spores known. But it must be good,
the tests of which were dryness and solubility in water. If
moist, it had too much chloride of calcium; if insoluble, too
much lime. Where corrosive sublimate failed, it must take its
place. In the dejections of patients, and in sputa, where there
was likely to be albumin, mercuric chloride was worse than use-
less. It coagulated the albumin, forming a protecting sheath,
within which the germs were secure from harm. As to the
connection between cholera asiatica and cholera nostras, he
thought the weight of evidence pointed to their common origin.
Continuity in disease would become pretty certain to such phy-
sicians as kept their mental eyes open. In scarlet fever it had
been observed that exposure sometimes produced symptoms so
mild that but few would be bold enough to make a diagnosis.
So far as the comma bacillus itself was concerned, the part it
played in the disease was not yet certain. A case had been re-
ported of a regiment of soldiers being attacked by cholera in
their barracks. After many deaths had occurred they were
ordered to tent out a short distance away. They drank the
same water, ate the same food, and attended to the same duties,
but the mere change of a few perches arrested the outbreak.
If their soiled linen, water, hands, or anything else likely to
convey micro-organisms had been responsible for the disease,
why did it cease on mere change of locality? If Koch was
right, while it was advisable for us to disinfect sewers now, it
would be a fatal policy to pursue during an epidemic of cholera.
We should thus kill the Bacterium termo, the natural enemy of
the comma bacillus, and give the latter a better chance to mul-
tiply.
Dr. Stub wished to mention that tannic acid as an injection
had been mentioned by him in his paper as having been very
efficient during the last epidemic in France, but he would object
to the use of glycerin because it could do no possible good, and
might do much harm, for it might deplete the mucous mem-
brane, when our aim should be to add water to the system, and
not to deplete the blood still more. He also thought that Dr.
Eccles's objection to the bichloride as a disinfectant because it
coagulated the albumin might be overcome by the fact that it
would kill the bacilli before it coagulated the albumin, and be-
sides, in the speaker's opinion, the bacilli were albuminoid
bodies themselves.
(To be concluded.)
BROOKLYN PATHOLOGICAL SOCIETY.
Meeting of February IS, 1885.
The President, Dr. B. F. Westbeook, in the Chair ;
Dr. A. H. P. Letjf, Secretary.
Necrosis of the Femur.— Dr. Justus E. Gregory presented
a small sequestrum removed from the inner side of the middle
third of the left femur at a point where the femoral artery lies
nearest to the shaft of the bone. February 15, 1883, the pa-
tient, a man aged forty-six years, consulted him in reference to
a carbuncle situated over the left shoulder blade, which was
treated by deep incisions. On the 20th of April he complained
of a swelling on the front of the left thigh in its upper two
thirds, which proved to be an abscess. This was freely laid
open and search made for diseased bone or periostitis, neither
of which was discovered. After thorough irrigation with bi-
chloride solution (1 to 2,000), large drainage-tubes were intro-
duced and the wound was packed with bichloride gauze. It
healed by granulation. In February, 1884, the speaker's atten-
tion was called to a sinus which had formed on the anterior
surface of the thigh about its middle third and taken a course
directly toward the femoral artery. From this sinus there was
a slight discharge of pus, and, upon passing a probe, diseased
bone was discovered. An operation for its removal was per-
formed by Dr. Wackerhagen on February 5 th. Esmarch's
bandage having been applied, alarge hand probe was introduced
into the sinus and followed by incision up to the femoral artery.
The opening was enlarged over the course of the vessel, and
when the latter was reached it was separated from the bone by
retractors, as it actually covered the cloaca. This was enlarged
and several small sequestra were removed. The patient recov-
ered, with a perfectly useful limb.
Dr. Kretzschmar desired to know how periostitis could be
diagnosticated by simple incision of an abscess.
Dr. Wackerhagen said he had believed at the time that the
abscess was due to bone disease, and if he was right it could be
better ascertained by the opening of the cavity.
The President remarked that periosteal abscess of the fe-
mur was usually so deep that it was hard to find; the abscess
in this case was superficial, and so out of the usual course.
Dr. Kretzschmar rejoined that he still failed to see how
simply opening the cavity would enable one to make the diag-
nosis.
Dr. Wackerhagen replied that the abscess was diffuse and
had to be opened to let out the pus, and he took advantage of
that fact to probe for any of the bone that might be diseased.
Self-mutilation by Amputation of the Genitals.— Dr. H.
D. Bliss gave the history of a case he had seen during the sum-
mer in the practice of his friend, Dr. J. H. Taylor, of Mount
Holly, N. J. A farmer became affected mentally after the death
of his wife. He grieved much at the loss of his wife, and, as
the neighbors afterward said, acted somewhat queer at times, but
continued his work as usual. One morning he was found with
his scrotum and penis amputated. The reason, as he explained
the next day, was that he had felt impelled to do it, for, as he
had been the cause of bis wife's death, he thought this would be a
relief; so, taking a razor, he had taken the entire external geni-
tals in the left hand, pulled them well out and up, and, with one
cut of the razor, severed the entire organs. They were afterward
found well connected together. He was not discovered for
some time, and it was several hours before the medical attend-
ant arrived. The haamorrhage, which had not been very con-
siderable, had nearly stopped, except a slight welling up around
the urethra, probably from the dorsal arteries of the penis.
This was slight, but continued troublesome for several days on
account of the difficulty of securing the vessels which lay in
close contact with the urethra. It could be stopped with serre-
Jines, but it would begin again every time a catheter was passed.
It was finally stopped by applying compound tincture of ben-
zoin. The cut with the razor had exposed the pyramidalis
muscle and removed the skin over the pubes, making a wound
that could scarcely be covered by the palm of the hand. It was
at first intended to dress it with carbolized water, but the nurse
allowed it to dry so often that a cloth dipped in carbolized oil
was kept over the parts, and the man made a good recovery.
The penis being put on the stretch at the time of the cut, the
urethra retracted about three fourths of an inch below the
surrounding tissue, and there was trouble in keeping it from
closing. Catheters of various kinds were tried — silver, rubber,
flexible, non-irritant, etc. — but all proved so irritating they had
to be discontinued and some other means resorted to. On
December 27th Dr. Taylor made a cut an inch and a half down
the perinceum, dissected up the skin, and trimmed the tissue so
that the integument could be stitched to the urethra. This was
done, and all closed with silver wire, and in one week, as the
doctor said, "ho had a good working urethra."
50
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
Among the points of interest in the case were the recovery
from the delirium, the speedy recovery of the patient, and the
small amount of hajmorrhage from so vascular a structure.
The President related a similar case that had occurred in
the Eastern District some years ago, in which the victim's para-
mour cut off his genitals with a razor, causing fatal hajmor-
rhage.
A Case of Hysterectomy for Cancer was then related by
Dr. W. C. Burke, -Jr., of South Norwalk, Conn. [It has already
been published.]
Dr. A. H. P. Leuf remarked that he fully coincided with
Dr. Burke in considering carcinoma at first local, and thought
that thorough eradication of the disease in loco, with the extir-
pation of the first set of lymphatic glands and intermediate
lymph-vessels in all cases, as an additional safeguard, would be
followed by satisfactory results, if done in time. Many lives,
he thought, were sacrificed because of a great lack of fearless
and intelligent surgery.
Dr. R. G. Eccles desired to know if any embryologist was
present to tell the society about the transition of embryonic
cells into pathological cells.
Dr. C. N. D. Jones said that the case just brought before us
was another one in favor of the operation.
The President remarked that many of these growths were
at first local and benign, and afterwrard became malignant.
This was especially true of the skin, for moles and other benign
affections of the integument sometimes, and perhaps in the ex-
perience of many present, became malignant. A case had oc-
curred in his experience about one year ago. The patient was
a lady who had a " mother's mark " two inches below Poupart's
ligament. He did not see it at the beginning, but believed it
was a mole, and not a naevus. Subsequently, when she had
been sewing with a machine, the irritation due to the friction
of her clothing while at work was painful, and caused bleeding.
When seen by him, the lesion looked like an excoriation, and it
was not raised more above the general surface than was usual
in moles. There was no perceptible involvement of the gland--.
He ordered an ointment. Six months later the patient returned
with the sore much worse, painful, bleeding freely, and emitting
a very offensive odor. He found a projecting mass about an
inch and a half in diameter and fully half an inch high. It
had the general appearance of a malignant growth. He re-
moved the whole mass at St. Mary's Hospital. Everything was
extirpated down to-the cribriform fascia, and the fascia lata
scraped for several inches around the original sore. Several
affected glands were removed at the same time. A few days
later one of the Sisters at the hospital called his attention to a
lump over the patient's iliac crest. There seemed to be no con-
nection between this lump and the wound. Two weeks later
these nodules developed over the whole body, and a few months
after the operation she died in horrible agony. It was hard to
account for the malignancy of this case by the accepted views of
cancer genesis. Paget's case of cancer at the outer side of the
thigh was referred to. The same was true of the female breast.
It was notoriously difficult to differentiate between benign and
malignant growths. As regarded Dr. Eccles's question, he would
say that it had been, and by many was still, maintained that all
cancerous growths were developed from the cells of the inter-
mediate layer of the embryo. Cohnheim had asserted that all
cancers were congenital. The whole being was abnormal from
the on-et, and only required an irritation to start the malignant
processes. The outer and inner layers of the embryo had be-
tween them undeveloped cells, which, by subsequent irritation,
became developed into malignant structures. Thus we met
with most of these formations in the uterus, gullet, etc. Cohn-
heim's views were opposed to those of Dr. Burke and others.
These latter gentlemen make it local, while the former would
have it general.
Dr. Ecci.es wished to know if Cohnheim's views could not
be reconciled with those of the other gentlemen by supposing
the irritation to extend after the local disease had existed for a
sufficient length of time.
The President replied that Cohnheim supposed that some
of the cells in many people had not properly developed, and
that it was at such places that cancer began.
Dr. Ecoi.es reiterated the question, whether these cells
passed through several stages or at once became cancerous.
The President replied that in embryonic life they became
differentiated by a comparatively immediate transition.
Dr. Andrew Otterson had seen a bad case of "cancer"
which, after excision, turned out not to be cancer. It was not
always easy to make a diagnosis, and more especially a progno-
sis. Of about twelve patients upon whom he had operated,
only two had survived for five years. In one the tumor had
been said to be certainly very malignant and in the other doubt-
ful. A former librarian of the Brooklyn Library, fifty years of
age, was on a step-ladder, and, while reaching up, fell and struck
his breast. It troubled him a good deal. He was under the
care of a good surgeon, and was advised to have a resulting
lump cut out. Some told him not to have it done. Eventually
the speaker cut it out. It came back again in the cicatrix
within a year, also involving some of the neighboring parts.
No glands appeared to be affected. It was again excised, and
again returned in two years and involved the body generally,
but more especially the spinal cord and other parts of the nerv-
ous system, as shown by post mortem examination. Another
case was that of an old woman in Fulton Market. A boy struck
her in the breast with a stone. The resulting nodule remained
for years. At last it began to suppurate, and all the neighbor-
ing glands were involved. Yet another case was that of a jani-
tor with a nodule of the size of a walnut on the shin from a fall
off a step-ladder. It became a suppurating and bleeding sore.
The stench was as bad as it could possibly be. The part was
very painful. The speaker removed the whole mass with a
ligature, and there never had been any return. The man lived
for many years, and died of a totally different trouble. He had
been sure that this was a case of malignant disease. He be-
lieved every practitioner could relate similar cases. As to the
indiscriminate removal of all nodules, he thought it impracti-
cable because of the objections on the part of patients.
Dr. Burke said that, as to the justifiability of hysterectomy,
he was sure that a large proportion of patients would be saved,
if surgically treated before it was too late. He had seen an
operation two days after bis, but the case was so far gone that
the patient did not live. There was no peritonitis, but death
was due to asthenia. In such advanced cases the operation
was not justifiable, but it was if done early and when the dis-
ease is local. He thought the operation would become more
popular.
Comminuted and Depressed Fracture of the Skull;
Trephining ; Fungus of the Dura Mater ; Recovery. — Dr.
Burke then read a paper with this title. [See page 36.]
Dr. R. G. Eccles asked if there had been other psychologi-
cal effects noticed than those that had been mentioned, for the
piece of bone driven into the brain must have entered at about
the speech center.
Dr. Burke replied that there had been no such symptoms.
Dr. Eocles: " Has he lost any words? "
Dr. Burke: "No."
Dr. A. Ross Matiieson related a case. A piece of frontal
and temporal bone about an inch and a half in diameter was
driven into the brain by a horse's kick. Fissuring extended
July 11, 1885.J
PROCEEDINGS
OF SOCIETIES.
51
completely across the frontal bone. The upper fragment over-
lapped the lower fragment. Considerable brain-substance was
lost. The case was also seen by Dr. Daniel Ay res, Dr. George
K. Smith, and Dr. H. Messenger Ayres. Those parts of the
bone that had been driven into the brain were removed. Dr.
Smith desired to correct the position of the overlapping frag-
ments, but, Dr. Ayres and the speaker objecting, they remained.
There was complete paralysis. Two weeks later a fungus duras
matris developed. It grew as large as the one in Dr. Burke's
case. He could not get rid of it by shaving it off a number of
times. At last it was sprinkled with sulphate of copper, and a
rubber compress was applied. Then it soon healed. At pres-
ent the patient was well and was an operator in a stock office
in Wall Street, New York. The overlapping in the frontal re-
gion no longer existed, and in its place could be seen a line of
pulsation, half an inch wide, extending all the way across the
forehead. He continued a little aphasic for about six weeks
after getting up. Now, however, he had no physical or mental
symptoms whatever.
Dr. Ecoles called attention to the fact that, according to
phrenologists, the patient ought to have lost the sense of atten-
tion after losing so much cerebral substance from such a local-
ity.
Dr. Matiieson stated that the loss of brain substance had
amounted to two or three ounces.
Dr. JosEPn H. Hunt desired to know if the opening in the
skull in Dr. Burke's case had been filled in by new bone.
Dr. Burke replied that it had not, and that at present it was
only covered with membrane and skin. During quiescence the
skin was sunken in, but when the patient became excited it
bulged out.
Dr. Hunt said he had been unusually interested, as he had
had a similar case some years ago. The skull was fractured at
the vertex and the fragment depressed about an inch. It was
removed by Dr. Jar vis S. Wight. The boy was quite well now.
There was no fungus duras matris. The scar looked almost like
a fontanelle.
Dr. Leuf remarked that he had seen Dr. Hunt's patient not
very long ago and had taken occasion to make some inquiries.
He was now a vigorous, healthy, and active young man, en-
gaged in rather hard work. Since the recovery from the injury
he had become irascible and rather quick-tempered, qualities
diametrically opposed to those he bad exhibited previous to the
receipt of the injury. The opening was now quite small and
triangular in outline. Pressure upon this opening caused the
patient to experience a sickish sensation, and, if it was increased,
he felt a gradual onset of insensibility. Further than this, he
was afraid to have the experiment tried.*
The President remarked that in Dr. Burke's case the motor
regions had been involved according to Ferrier and Rolando.
Brown- Sequard held that, if one side was injured and its func-
tions were abolished, the other side would assume them in addi-
tion to its own. Dr. Burke's case seemed to be a demonstration
of the latter view.
Dr. Burke replied that the case had struck him as being so
unusual that he had closely observed it from the beginning, but
* Note by Dr. Leuf. — Because of the interest attached to this case,
1 would mention another fact. Since the meeting of the society the
opportunity presented itself to me to sail in a yacht (less than ten days
previous to this writing), which was solely managed by Dr. Hunt's former
patient. It was done with skill, after a whole morning and early after-
noon's hard work of rigging up for the first trip of the season. The
sail was such that it required no ordinary amount of skill, care, and in-
genuity to get along without mishaps, of which latter we had no expe-
rience whatever. This in addition to the above-noted facts connected
with the after-effects of loss of brain-substance.
could not say that he had noticed anything in addition to what
had already been stated.
Dr. Otterson mentioned a case that he had had in which
the brain oozed away for years. Afterward the patient became
a conductor on a railway car. His intellect was not in the least
impaired. He had never had any unpleasant symptoms of any
kind.
OBSTETRICAL SOCIETY OF PHILADELPHIA.
Meeting of June 4, 1885.
[Continued from, page 24.)
Gestation in a Sarcomatous Uterus simulating Extra-
uterine Pregnancy. — Dr. Bernardy related the following
case: On the 3d of October, 1884, he was requested to visit
Mrs. McG., a delicate woman, about thirty years old, whom he
found suffering with double pneumonia. At the same time he
was told that she was five months pregnant. The abdomen
was rather large for that period. On the 5th she complained
of a sharp pain in the right inguinal region, which required
large doses of morphine before any relief was obtained. He
found the right inguinal region filled by an immense growth
reaching almost to the lower border of the liver. The uterus,
or what appeared to be the uterus, was enlarged and pushed
well toward the left side. The right side of the pelvis was filled
by a growth. At first he thought he detected fluctuation, but
closer examination showed the growth to be hard to the touch.
The uterus was immovable, the neck being somewhat absorbed
and the os tilted up behind the pubes. To reach it, the finger
had to be passed well upward ; it was closed and soft. The
patient had never had any uterine trouble. The menses had
never appeared after her marriage, which occurred one week
after a period. Her health remained good for three months
after marriage, when, while out walking, she was suddenly
seized with a sharp lancinating pain in the right side of the
abdomen. The pain was so great that she almost fainted, bnt
finally reached home and went to bed. No physician was called
in. The next day there were slight traces of blood on her night-
dress. Under absolute rest the pain subsided, and at the end
of a week she was about her household duties. The pain in
the side returned if she exerted herself. Sexual intercourse
was painful and was followed by traces of blood the next day.
Believing that the symptoms pointed to either extra-uterine
pregnancy or a tumor complicating pregnancy, he asked Dr.
Goodell to meet him. By the time the consultation was held,
on the 8th, a severe attack of peritonitis had begun. A close
examination was therefore impossible. On account of the dis-
tended and painful condition of the abdomen, the outline of the
growth or uterus could not be traced. It was decided that
the symptoms and history pointed to extra-uterine pregnancy,
but, whether the uterus contained a tumor or a child, in the
present condition of the patient it was impossible to decide.
By the 16th the peritonitis was under control, but the lungs
were no better. On the 19th he was sent for, the messenger
stating that there was a renewal of the peritonitis. He found
the patient in active labor, the foetus descending rapidly. In
half an hour labor was completed. He readily detected the
large growth filling the upper portion of the right side of the
pelvis; the uterus was surrounded by a hard growth. The
cervix was hard. From this time the lungs improved, but the
patient remained extremely weak and there was a constant
dribbling of blood from the vagina. November 3d, the growth
was still present and the cervix hard, and he began to think of
malignant disease in connection with the tumor. He had ap-
plied to the abdomen, night and morning, an ointment of mer-
curial ointment, belladonna, and iodine, which seemingly had
52
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jonn.,
the effect of causing the absorption of the large growth, but the
mass surrounding the uterus remained the same. On the 27th
vomiting occurred and was arrested with difficulty ; there was
a bloody discharge from the vagina and a constant sore feeling
over the region of the uterus, which was still toward the left
side. The patient was extremely weak ; the slightest exertion
exhausted her and brought on bleeding from the uterus. De-
cember 26th lie found her suffering from pleurisy, the left pleu-
ral cavity being full of fluid. January 1st abdominal dropsy
had set in. A consultation with Dr. Goodell was held, and a
positive diagnosis of malignant disease was made. It was
thought that death might occur at any moment, and she died
suddenly the same evening.
The post-mortem examination, by Dr. E. A. Russell, showed
the entire abdominal cavity greatly distended with a dark fluid
full of broken-down lymph. The intestines were forced upward.
There were slight evidences of beginning peritonitis. A por-
tion of the ileum on the right side presented a black, unhealthy
appearance bordering on gangrene. The uterus was increased
in size. The outer surface presented an irregular mottled ap-
pearance, and large veins covered its surface. At the fundus
there appeared a spot, about one inch in diameter, of a bluish
tinge. On pressure by the finger the surface readily broke, and
underneath was a cavity, of about the size of a large hickory-
nut, which did not communicate with the interior of the uterus.
The cavity of the uterus was found to be almost obliterated ;
the tumor seemed to have entirely absorbed the true uterine
tissue with the exception of the neck. In the body of the
tumor were observed small masses or growths varying in size
up to that of an egg. The ovaries were small and seemed to
have participated in the general disease. Microscopic examina-
tion proved the tumor to be an adeno-sarcotna.
At first the speaker had been convinced that he had a case
of extra-uterine pregnancy ; but the peculiar hardness of the
tumor made him doubtful. Here was a patient that had never
had any uterine ailment, who married, became pregnant, at the
end of the third month, without any premonition ; while quietly
walking, was seized with pain of an excruciating nature in the
right side, went to bed and remained quiet, and the next day
blood flowed from the vagina. She remained comparatively
■well for two months and a half more, when she was again sud-
denly seized with pain in the same side, followed by peritonitis.
A tumor was found in the affected side; the uterus was en-
larged, but not sufficiently so for a five and a half months' preg-
nancy, the os giving no signs of that softening which should
accompany pregnancy. Could we have a group of symptoms
more allied to those of extra-uterine pregnancy?
Infant Feeding.— Dr. J. M. Keating said that, at his re-
quest, Dr. Charles Potts had instituted a series of experiments
which had a decided practical value, and they hoped to present
them to the society at an early date. He desired to place on
record a statement of the results so far reached, which appeared
to be interesting and important. The question often arose, Was
it of advantage or not for an infant to be partly nursed and
partly bottle-fed? What action had milk upon starch, if any?
To answer this the following tests were made: 1. A sample of
milk composed of the milk of several women, contained, ac-
cording to a quantitative estimation by Fehling's method, 6-84
per cent, of sugar. Ten c. cm. of this milk were then taken, f
gramme of powdered starch was added, and the mixture was
allowed to stand at a temperature of 99° F. for thirty minutes,
after which 5 c. cm. diluted with 45 c. cm. of distilled water, were
tested and showed 8-62 per cent, of sugar. The other 5 c. cm.,
after standing sixty minutes, gave 9-09 per cent. 2. Another
sample, found to contain 7-14 per cent, of sugar, had % gramme
of powdered starcli added as in No. 1. In thirty minutes it gave
9-803 per cent, of sugar in 5 c. cm. The other 5 c. cm., after
remaining sixty minutes, gave 8-62 per cent. Possibly part
of the sugar deposited was drawn off with the first 5 c. cm.
3. Another sample showed 6-32 per cent, of sugar, and, after
the addition of starch as before, gave in the first 5 c. cm. 8*19
per ceut., and in the next 5 c. cm. 7'93 per cent. These inves-
tigations showed that the women's milk gave an increase of
sugar after digesting with starch. 4. A sample of cow's milk
was tested and found to contain 3-87 per cent, of sugar. To
this was added £ gramme of starch to 10 c. cm. At the end of
thirty minutes 5 c. cm., diluted with 45 c. cm. of distilled water,
showed no increase of sugar. 5. A sample of cow's milk gave
4 per cent, of sugar, and was treated as before, but at the end
of thirty minutes, and then sixty minutes, it gave the same
result. G. Another sample of cow's milk gave 3-703 per cent,
of sugar. It was treated as before, with the same amount of
starcli. In thirty minutes 5 c. cm. gave the same result ; in sixty
minutes 5 c. cm. gave the same result. These investigations
showed that cow's milk gave no increase of sugar after the addi-
tion of starch. Did the acidity of cow's milk prevent the
sugar change? Did the sugar change continue in an acid me-
dium? 7. Another sample of human milk — from one woman
— yielded 6-25 per cent, of sugar. Starch was added as before.
In thirty minutes 5 c. cm. gave 7-14, and in sixty minutes 5 c. cm.
gave 7*6 per cent, of sugar. To 10 c. cm. of this milk (contain-
ing fi-25 per cent, of sugar) a few drops of dilute hydrochloric
acid, enough to faintly acidulate it, were added, and then i
gramme of starch, and it was allowed to stand as before. In
thirty minutes 5 c. cm. gave 6"41 per cent., and in sixty minutes
5 c. cm. gave 7*35 per cent, of sugar. 8. Another sample of
woman's milk without starch gave 6"17 per cent., with starch
7 24 per cent. Ten c. cm. of the same, acidulated with hydro-
chloric acid, diluted, gave in thirty minutes 7*35 per cent. In
these tests 10 c. cm. of Fehling's solution were used with 40 c. cm.
of distilled water. If future investigations proved the correct-
ness of these statements, we might safely assert that the nurs-
ing woman might advantageously supplement her breast milk
with some well-prepared digestible form of food containing a
small quantity of starch, and also that the anxiolytic ferment
would remain active in the slightly acid stomach of the infant.
The Surgical Treatment of Infants.— By invitation, Dr.
DeForeest Wiixakd read the following paper:
Your committee having invited me to speak to you to-night
upon the surgical treatment of infants, I purpose to confine my
remarks chiefly to personal experiences in the means of reliev-
ing the principal surgical difficulties which are met with during
the first two years of life. If the subject shall occasionally lead
me to mention older children, it will be because the line be-
tween infancy and childhood is not a marked and well-defined
one. As you are all active practitioners also, it will be unne-
cessary for me to dwell upon detail, and I shall only touch upon
practical points in treatment.
The surgery of childhood, as compared with that of adult
life, is, aside even from congenital defects, sufficiently marked
and distinctive to entitle it to separate consideration. First of
all must the children's surgeon acquaint himself with the anato-
my of the child. This is rarely done, as the ordinary adult dis-
sections during a college course give little idea of the size and
position of the individual elements as seen in the infant. In
consequence of ignorance upon this practical point many griev-
ous failures have occurred. After unusually large opportunities
for the study of both normal and abnormal tissues in the diminu-
tive frame, I am still frequently surprised to note the exceeding
smallness of different organs and canals.
Another essential element in the surgeon is tact in the man-
agement of the little ones, especially when dealing with those
July 11, 1885.1
PROCEEDINGS OF SOCIETIES.
53
betweenthe ages of two and ten. In hospital cases but little
history is attainable, and much depends upon quick perception.
Naturally fearful of pain, the patient's mind must be diverted
and engaged, or great difficulties in diagnosis will often occur
from the fright and struggling. The operator not in sympathy
with children can never secure their confidence. Much will
often be gained by quiet observation. It is not a month since
my opinion, which at the first few moments of the consultation
had been favorable to tracheotomy, was changed by five min-
utes' close watching, and the result proved the correctness of
the procedure. To the person, however, who will carefully
study individuality as well as disease, no department of medi-
cine offers so pleasant a return for his labors. My personal
experience with children has perhaps made me more hopeful in
regard to the power of such individuals to endure pain, shock,
and disease, than would be indicated by the expressions of other
authors, but to me there is no domain of surgery so attractive
and gratifying as the treatment of children below the age of
puberty. Their natural condition is that of hopefulness, and, as
soon as the depressing influence of shock, pain, or fear is re-
moved, the normal resiliency of mind and body asserts itself
with such rapidity that the results are often surprising.
Again, a child has only inherited taints of constitution to
contend against; his viscera are ordinarily in a healthy condi-
tion ; an adult has not only hereditary but all the acquired vices
occasioned by misuse or abuse of any organ or sets of organs, a
circumstance which often turns the scale in the struggle between
life and death. Take, for example, the single instance of the
outraging of tissues by either the moderate or the excessive use
of alcohol, and every surgeon will testify that even slight
wounds may, in such an individual, quickly develop a fatal at-
tack of mania a potu. Tetanus is not more frequent in infants
than in adults, notwithstanding the tendency of the former to
nerve excitability.
In regard to anaesthetics, my experience is that great benefit
is obtained by the use of ether when pain can thereby be pre-
vented. In the first weeks of existence I admit that a feeble
vitality would contra-indicate its use, although I have success-
fully administered it to an infant three days old. After the first
or second month, I see no reason why we should needlessly in-
flict pain upon an infant simply because we can control it by
brute force. In the examination of fractures great suffering is
often inflicted by careless and frequent manipulation, and, unless
the diagnosis is easy and positive, unconsciousness should be
produced. No case of boue injury should ever be passed by
undiagnosticated when ether will solve the question. In the
opening of abscesses the " primary quieting influence " of ether
is so readily obtained that it should be brought into use when-
ever practicable, as keenness of pain can thereby be avoided.
Fear plays an important part, aDd may depress the child's
system even more than pain ; hence great caution should be ob-
served that all knowledge of any operative procedure should be
guarded against. When the day for action arrives, let the sur-
geon quietly and gently state to the little one, if it has arrived
at years of reason, just what it is proposed to do, at the same
time assuring him that no pain will be experienced, and, if such
words are followed by firm, speedy, and judicious management,
much agitation and fear will be avoided. All preparations
should be made out of sight and hearing of the patient, and in-
struments need never be seen by him, except when a strong
impression is intended to be made upon the mind of a mastur-
bating boy requiring circumcision, in which case ether may
also be omitted.
One word in regard to the method of anaesthetization. It
is but natural that a child should be distrustful of any attempt
to deprive him of consciousness, a fear which is greatly in-
creased by the injudicious and greatly-to-be-condemned habit
of many parents, who systematically threaten their offspring
with the expression, " The doctor will come and cut your head
off." A few kind words will often quiet the agitation, and
simple directions as to the method of breathing will save many
minutes of struggling resistance. With very young children,
the first smell of ether may be masked by permitting them to
see cologne poured upon the towel, after which ether may be
quietly added, and they will feel that it is a perfume that they
are breathing. This device has frequently served me a good
purpose. I always allow a good admixture of fresh air for the
first moment, but, when the child actually begins to cry, then
quick action answers best. The towel should now be well satu-
rated and held firmly over nose and mouth until two or three
strong screams and inhalations yield a full primary impression,
which can be gradually followed up to complete anaesthesia
with safety.
Should any symptoms of ether narcosis occur, it is so easy
to depress the head of a child, or to perform artificial respira-
tion by acting upon the ribs, that serious accidents are infre-
quent. Subsequent vomiting is very common but is not
persistent, and is easily quieted by a small hypodermic of
morphine, a procedure which ordinarily brings quiet sleep to
the patient. If the child is feeble, I always allow milk up to
within two or three hours of the operation, and then adminis-
ter wine or whisky in water immediately before giving the
anaesthetic. Milk with lime-water and whisky is usually re-
tained within ten minutes after the first vomiting on rousing.
In tedious excisions, not only should preliminary precautions be
taken to secure against prostration by shock, but hot- water
bags should be ready for use, which, with hypodermics of
brandy, may succeed in tiding over a temporary depression
which would otherwise end in death. When the loss of blood
has been great, especially in acute surgery, important assistance
may be gained by transfusion, either of blood or of a warm
saline solution.
Under the head of arrest of haemorrhage I would strongly
advocate the use of animal ligatures, since the pain often inci-
dent upon the removal of threads greatly disturbs the needed
quietude of wound and mind.
Thorough asepsis and antisepsis are especially valuable
since we not only secure the admirable results that are attain-
able by their use, but are also enabled to disturb the child with
far less frequency. I am now treating a girl with a railroad
crush of the leg which would thoroughly have justified amputa-
tion, yet which, under corrosive-sublimate dressings, has been
touched but six times in as many weeks, even though extensive
sloughing has occurred. Save upon one occasion, at the height
of the process of tissue-death, the applications have been taken
away perfectly sweet, and the child has the promise of a reason-
ably good limb. In my septic days I certainly was never able to
carry a patient through such a process and keep the tempera-
ture, as has been done in this case, below 99o° F. all the time,
and usually but slightly above 98°. With infrequent dressings,
the irritation of the child is but slight, and, if pain is also ab-
sent, contentment is the rule, under proper nursing.
I can not too strongly emphasize the importance of this lat-
ter condition. A kind, quiet, gentle nurse is one of the most
valuable assistants in the real progress of the case, especially
during the first week following an operation. Such care can
not be delegated to untrained and careless people, hence it is
absolutely necessary that children should be in separate hospi-
tals, or in separate wards, under the be3t of care-takers. Even
in private practice the mother is rarely the best nurse for a
child past two or three years of age, and a skilled attendant
answers best. In hospital practice I have often been surprised
54
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Joub.,,
to see how contented and patient the majority of children of
even three years of age will become if the mother maintains a
judicious absence and the nurse is efficient and kind.
Another point which I wish most emphatically to emphasize
to-night is the fact that congenital defects are most inexcusably
and persistently neglected by even good practitioners, under
the mistaken opinion either that nothing can be done, or that a
later period will be early enough. The consequence is that
many unfortunates become helpless and hopeless cripples by
their physicians' advice, since, passing out of his sight and mind,
the neglect engendered by his direction, " wait," is fostered by
parents, ever ready to postpone a dreaded day.
Turning to some of the special surgical diseases of infants, I
would say that it is my intention to simply touch upon a few
points of treatment without regard to definite arrangement or
order, since to consider almost any one of the conditions in full
would require an entire evening's discussion.
In a new-born child the first most probable trouble requir-
ing surgical relief will be imperforate anus or rectum. Such a
condition is not improbable when we remember that the intes-
tine is formed as a closed tube. If the malformation is simply
one of occlusion of the anus by a membrane, it would seem to
be the easiest of procedures for any practitioner to make an
opening, yet I have seen children permitted to die with the
entire ischio-rectal fossa and perinseum bulging with retained
fasces, when a simple puncture through a membrane closing an
otherwise normal anus would have given immediate relief. This
timidity may perhaps be explained by the fact that occluded
anus and imperforate anus are confounded with imperforate
rectum and the case is given up as hopeless. In imperforate
anus the operation is still a simple one, since a crucial incision,
together with stitching of the mucous membrane to the skin
and subsequent dilatation with the finger or probe, is all that is
required.
When the anus is normal and patulous, but the rectum is
occluded by a membrane, or is actually absent, a much more
serious condition presents itself, the difficulty increasing in pro-
portion to the extent of the deficiency. Should no meconium
be passed within the first twenty-four hours, a careful search
should be instituted. The little finger or a catheter passed into
the anus will detect the obstruction, or, if the anus is absent,
the vagina, if present, may be explored for abnormal fistulas.
As soon as the presence of faces can be discovered in the fossa,
a careful dissection should be made, keeping well backward, so
as to avoid the vagina, or the urethra and bladder. A catheter
should always mark the position of the urethra. There is but
little danger, even in deep incisions, if the region of the coccyx
and sacrum is followed. The gut found, it should be drawn
down as far as possible and secured, a channel being maintained
through the lower rectal region, if necessary, by the finger or
by bougies, the latter of which should not, however, be retained
constantly in position. There is much less danger from subse-
quent haemorrhage if the external incision is free, and no fear
need be entertained about the ultimate retention of fasces, as, if
the child escapes peritonitis and other inflammations, good con-
trol of the bowel is always secured ; in fact, the chief subsequent
danger lies in the formation of stricture. When the length of
the bowel will not permit it to reach to the site of the anus, the
new opening may be made nearer to the sacrum. Should no
trace of the rectum be found within two inches of the anus, it
is unsafe to further explore a region where the peritonaeum
would be liable to injury ; either left inguinal or left lumbar
colotomy should be performed. The right groin is to be selected
if there are evidences of absence of the sigmoid flexure. The
left inguinal position gives a better subsequent opportunity of
passing a bougie downward into the rectum and thus establish-
ing a proper anus. If the colon is full, it will not be difficult to
find. In cases of doubt, its distension by air or water through
a hypodermic needle would determine its termination. Abnor-
mal openings into the vagina, bladder, or urethra rarely require
early operation, but, in non-retention of fasces at a later age,
Iiizzoli's plan of procedure is a good one.
Later in childhood, the surgeon is often compelled to treat
another condition of the rectum, namely, prolapse. This, if
excessive and non-yielding to replacement, astringent applica-
tions, hot water bathings, and general constitutional measures,
must be cured by the production of linear eschars by nitric
acid.
The genito-urinary organs may also require attention imme-
diately after birth. A simple occluded urethra is easily relieved
by the careful introduction of a sound or catheter. Epispadias^
hypospadias, and exstrophy of the Madder should not be allowed
to go on to adult life without relief. As soon as the child has
passed its dentition period, a plastic operation should be at-
tempted for relief, since the mental and moral effect of such a
deformity has often a marked influence upon the lives of the
unfortunates. Adhesion of the vulva or nymphm should not be
overlooked, since not only does the nervous system suffer, but
the parts may be improperly developed. Separation can almost
always be accomplished by the finger or by a probe. An abso-
lutely imperforate hymen should never be allowed to exist if
discovered, since, if permitted to impede the menstrual flow, at
a later period, serious and even fatal results may follow its di-
vision, if the uterus and Fallopian tubes have become dilated by
the imprisoned secretion. Imperforate vagina should receive
at least careful diagnostic attention to detect the presence of a
uterus, and, if this is not absent, fuller development will be
secured if the passage can he opened during the first few years
of life. With a catheter in the urethra and a finger in the
rectum, a careful operator can explore safely. I have met with
several cases in which the penis was preternaturally short and
ill formed, the body of the organ, during flaccidity, being almost
entirely concealed in the fatty tissues of the pubes. *In such
instances I have removed the prepuce during the first three
months of life, and have cut away all restricting bands of skin
and connective tissue, sometimes even drawing beneath the
penis an extra flap of skin when the corpus spongiosum has been
short and dwarfed. By such means the fullest amouDt of
growth is encouraged.
Adherent and contracted prepuce, or phimosis, has been the
subject of much discussion in regard to its causal influence upon
certain nervous manifestations. My views upon this subject
have been already published,* and, after two years of additional
experience, during which time I have been brought daily in
contact with this class of cases, I can reiterate what I then
stated, Damely, that, while more or less adhesion is an almost
constant and normal condition, yet, when urinary, choreic,
paretic, or any other nervous symptoms develop, a careful in-
vestigation should never be omitted, since a direct relation will
in a certain number of cases be clearly evidenced, and removal
of the cause will speedily cure the manifestation. The fact that
even circumcision does not relieve the symptoms is undoubtedly
true in many instances, and I have never maintained that pre-
putial adhesion and narrowing was anything more than one of
several factors which should be carefully scrutinized. I have
only urged that its influence should not be overlooked, and,
when so simple an operation as stripping the prepuce from the
glans by the thumbs, or possibly by the use of a probe, is all-
sufficient, there can certainly be no argument against removing
this one factor. My opinion in regard to the feasibility of
* "Philadelphia Medical Times," June 30, 1883.
July 11, 1885.1
MISCELLANY.
55
drawing back the prepuce in young children, even when the
opening seems scarcely pin-hole in diameter, has been greatly
strengthened, and circumcision is only necessary when the sim-
pler method described fails to secure a prepuce freely movable
over a normal glans. Dilatation even is but rarely required, a
few minutes of continuous pressure soon revealing the mucous
layer, adherent perhaps just about the meatus, which, when
loosened, permits the head to pass through the opening, and
the corona is freed with the thumbs. Should temporary para-
phimosis occur, two probes or a hair-pin slipped beneath the
constriction will easily permit replacement.
(7b be concluded.)
The American Medical Association and the International Medical
Congress.—" The meeting of the American Medical Association, held at
New Orleans during the past month," says the " Kansas City Medical
Record," in its June issue, " did not prove to be as much of a success
as was anticipated. We presume this may be accounted for on the
ground of the location, the country in the vicinity of New Orleans be-
ing sparsely occupied by physicians, and the territory well occupied by
the profession being at a great distance, rendering it a tedious journey
at a great sacrifice of time. Hence the attendance from our large East-
ern and Northern cities was very light.
"There were about five hundred physicians present, mostly from the
South and West. The papers read, both in general^ session and sec-
tions, were quite practical as a rule, and full of interest, and received a
pretty thorough discussion.
" Many of the leading representative men who usually attend the
meetings being absent detracted from the general interest, and pre-
vented the meeting reaching the average standard of American Medical
Association meetings. . . .
" The second day of the meeting was ushered in by a somewhat ver-
bose discussion regarding the action of the committee relative to the
International Medical Congress. From our best information regarding
the gentlemen who were instrumental in initiating this uncalled-for
wind-storm, we fancy the trouble originated from disappointment
They are sore-heads of the ' rule or ruin ' type. Some of these men
have for years endeavored to supply the wind-power for the American
Medical Association meetings.
" The International Medical Congress requires a more reliable power
— a steadier power ; hence these dress-parade sort of fellows were, of
necessity to the welfare of the Congress, relegated to the rear.
" In order to conceal the true character of the charges, they hid
behind the new-code prejudices charging that new-code men were put
on the committees. However objectionable the new-code men may be,
we hope they are governed by purer principles than men whom we
know to be ostensibly sticklers for old-code theories, but are practically
no-code practitioners, except such as will give them personal aggran-
dizement.
" We have carefully looked over the ' rules and preliminary organi-
zation,' and can see no reason to find fault with the action of the com-
mittee. We feel entirely satisfied that they have acted in the best in-
terest of the American profession in general. Nearly all the States, the
District of Columbia, and Canada have been represented by the appoint-
ment of prominent and distinguished physicians on the committees and
sections. New York, having the largest number of widely known men,
is justly entitled to a larger number of representatives, and therefore
has 68 appointments ; Pennsylvania, which might be expected to come
next, has 48; Massachusetts, 32; Illinois, 18; Ohio, 15; District of
Columbia, 18; Missouri, 8. A few States are left out, which can be
the only tangible objection to the appointments.
" It must not be forgotten that the States so largely represented are
those in which most of the medical teachers and authors reside, without
whom, be they new- or old-code men, the American profession could
not be represented in its best light, which, above everything of a tech-
nical nature, should be sought after."
The Use of Cocaine in Nervous Affections. — At the recent meeting
of the American Neurological Association, Dr. J. K. Bauduy, of St.
Louis, read a paper in which he recounted his experience with the use
of cocaine in the treatment of certain forms of psychical disturbance.
We expect to publish Dr. Bauduy's paper shortly. In the mean time,
we would call attention to a letter which has been shown us, written by
Dr. L. Bremer, of St. Louis, from which we make the following ex-
tracts: "Dr. Bauduy, of this "city, has been using the cocaine in cases
of melancholia with the happiest results. During a recent visit at St.
Vincent's Hospital I was, by the kindness of the doctor, afforded an
opportunity of witnessing the rapid and wonderful effect which the
hypodermic injection of one grain of the drug produced in the affection
named. W. EL, aged seventeen, who was under my treatment before
his admission to the hospital, for hebephrenia, and whose mental state
I am thoroughly familiar with, was, on our visit, found in a condition
of great depression. Although he knew me well, he refused to speak
to or recognize me. The expression of his face was that of utter de-
jection, despair, and disgust. All efforts to elicit an answer to my
questions failed ; he remained wrapped up in a sullen silence. The
injection of one grain of cocaine changed the scene as by magic. Four
minutes after the introduction of the drug the patient began to talk ;
the spell was broken, and he conversed freely and intelligently on the
nature of his trouble. The almost mathematical precision of the effect
of the remedy could only be compared to that of morphine in certain
nervous affections.
" The second case in which the cocaine was tried in my presence,
and yielded a like brilliant resifTt, was that of a young man suffering
from a severe form of melancholia combined with a refusal to take
nourishment. Five minutes after the administration of the drug he
became quiet and partook readily of the nourishment offered to him.
This patient would never eat except when under the influence of the
drug; it was employed for the first time when he was approaching
inanition, to avert which the feeding-tube was thought of as a last
resort. ... To my knowledge, Dr. Bauduy has been the first to try co-
caine in melancholia."
Dr. Bauduy seems to have been the first also to suggest the use of
cocaine for the morning sickness of pregnancy. An interesting account
of Dr. Schenck's experience with the remedy for that distressing con-
dition will be found in the report of the proceedings of the St. Louis
Medico-Chirurgical Society, published in the " St. Louis Courier of Medi-
cine " for May, where it is expressly stated that the cocaine was used at
the suggestion of Dr. Bauduy.
The New York Polyclinic. — Dr. M. Allen Starr has been elected
professor of diseases of the mind and nervous system in the New York
Polyclinic.
The " International Journal of the Medical Sciences." — Beginning
with the issue for January, 1886, according to the "British Medical
Journal," this will be the title of the " Americal Journal of the Medical
Sciences," Dr. Hays continuing as the American editor, and Mr. Malcolm
Morris being the European editor.
The Health of the State of New York. — It appears, by the " Month-
ly Bulletin " issued by the State Board of Health for the month of May,
that the total reported mortality was 6,542, the percentage of infant
mortality being 32'23. In each thousand deaths there were 154 70
from zymotic diseases, including 26-83 from measles, 18'10 from scarlet
fever, and 48"91 from croup and diphtheria.
The Health of Michigan. — From a statement issued by the secre-
tary of the State Board of Health, Dr. Henry B. Baker, we find that,
during the month of June, diphtheria was reported from forty-one
places, scarlet fever from twenty-seven, measles from sixteen, and
small-pox from two.
The Missouri State Board of Health was lately reorganized by the
choice of Mr. William Gentry as president, Dr. George lloman as secre-
tary, and Mr. J. B. Prather as treasurer.
56
MISCELLANY.
[N. Y. Med. Jons.
THERAPEUTICAL NOTES.
A New Species of Agaric. — Grossi, says the " Gazzetta degli ospi-
tali " (quoting from " Kif. med."), has recently made a study of a gigan-
tic species of agaric, the Polyporus senex, found on the coast of Chile,
the absorbent properties of which are remarkable. Although it is in-
soluble in ether, in chloroform, and in alcohol, it effervesces in the pres-
ence of bicarbonate of sodium, becomes smooth and unctuous, breaks
up, and dissolves. Grossi has made use of it as a styptic, and regards
it as a specific in cases of haemorrhage from wounded arteries that are
too small to tie, and too large to be controlled by other styptics ; also
in the hsemorrhagic diathesis. He has employed it for night-sweats
also, after the following formula :
Polyporus xenex 3 \ grains ;
Bicarbonate of sodium 15 "
Distilled water 3 ounces ;
Gum arabic 75 grains.
A tablespoonful to be taken at night.
A New Basis for Ointments and Suppositories. — In the same publi-
cations it is stated that the seeds of the //<y/<" sphndidn and the Hopea
aspera, if not those of some other species, furnish a fatty matter, known
in the Islands of Sunda as myniak-tangkawank or myniaksangkawank,
which is used in the industrial arts, and seems likely to answer in the
preparation of ointments and suppositories.
The Treatment of Goitre with Iodoform Injections. — Thiroux
(These de Paris, 1884; "Rev. med.") records several cases in which
interstitial injections of iodoform were followed by considerable im-
provement and even cure. At the military hospital at Bordeaux these
injections have been found to give so jnuch pain, due probably to the
ether in which the iodoform was dissolved, that their use has been
given tip.
Parthenine in the Treatment of Facial Neuralgia. — Tovar has
experimented with this alkaloid in cases of facial neuralgia (" Gazz.
med. Ital.-Lombard."). Giving a tenth of a grain every hour for four
hours, and then decreasing the size and frequency of the dose, he cured
rather a severe case in a week. Parthenine is obtained from Parthe-
mum hysteropJwrus, an herb growing in Jamaica, where it is much
used for cutaneous affections.
Anisic Acid as an Antipyretic. — This substance (Ibid.), obtained
by the oxidation of oil of anise, takes the form of colorless prismatic
crystals soluble in alcohol and in ether. It has antiseptic properties,
also an antipyretic action analogous to that of salicylic acid. It should
be used with caution, as large doses injected into the veins of various
animals have caused epileptoid convulsions.
A Ready Method of stopping Hiccough. — A Brazilian physician,
Dr. Ramos ("Bull. gen. de therap."), states that refrigeration of the
lobe of the ear will stop hiccough, whatever its cause may be. Very
slight refrigeration will answer — the application of cold water or even
of saliva being sufficient.
The Fruit of the Calabash Tree as a Purgative. — According to
Peckolt (" Nouveaux remedes"), both the pulp and the expressed juice
of this South American tree, the Cresccntia cujete [Linnaeus], have long
been used as laxatives in Brazil. The alcoholic extract, in doses of a
grain and a half, is a laxative, and acts as a drastic in doses of seven
or eight grains. The fresh pulp is also employed as an application in
cases of erysipelas. It is boiled with water until it forms a black
paste, then vinegar is added, and the mixture is boiled again. It is
applied spread on linen.
Hydrofluorate of Quinine. — According to Weddel (Ibid.), this salt
is soluble in water and in alcohol. He has used it in the treatment of
hepatic engorgements of malarial origin, in which, he thinks, fluorine
and the fluorides have a beneficial action. He has observed the same
in rickets and other nutritive diseases of the bones.
Paraldehyde as a Hypnotic. — At a recent meeting of the North of
Ireland Branch of the British Medical Association (" Brit. Med. Jour."),
Mr. Hodgson, of Brighton, gave his experience with this drug in cases of
insomnia unaccompanied by pain, especially in mania, hypochondriasis,
delirium tremens, and [so the account states] migraine. As compared
with chloral, it had the advantage of not being a cardiac depressant.
For gout, both acute and chronic, he strongly recommended it, finding
that sleep was obtained, while the solid constituents of the urine were
increased rather than diminished. When either the throat or the stom-
ach was inflamed, it was unsuitable, owing to its pungency, and this
quality rendered free dilution always necessary. As an anodyne, he
considered it weak, but he had found that it heightened the effect of
morphine.
Anagyrine. — This is the name given to an alkaloid extracted by
Hardy and Gallois from Anayyrix ftetida and A. indica. At a recent
meeting of the Societe de biologic (" Gaz. hebdom. de med. et de chir."),
M. Hardy reported that small doses had been found to act as a tonic,
but that large doses, given to small animals, produced death by arrest-
ing the respiration.
Deelina Oil in the Treatment of Skin Diseases. — Dr. John Rob-
erts, of Chester, England (" Practitioner"), gives brief notes of a num-
ber of cases of skin disease, chiefly of an eczeruatous character, in
which he has used " oleum deelinae " as a topical application. He con-
siders it superior to all other fatty substances for the purpose. He
never uses it during the acute stage. Before it is applied the parts are
bathed with warm bran-water or oatmeal-water, and then carefully and
gently dried. All that is said of the nature of the oil is that it is " an-
other member of the hydro-carbon family," and that it is " manufac-
tured on the banks of the Dee, by the Dee Oil Company, by a process
of refining," etc. We find nothing in the article to indicate whether it
is a fish-oil, a petroleum product, or of vegetable origin. It is said that
it is clean and inodorous, does not become rancid, and leaves little or
no greasiness after its application.
Iodoform in the Treatment of Syphilis. — Dr. H. Macnaughton
clones (Ibid.) states his experience of the value of iodoform adminis-
tered internally in certain cases of syphilis in which the iodides appeared
to have little effect. He does not generally give it in larger doses than
a grain or a grain and a half, three times a day. He continues its use,
unless it is contra-indicated by some sense of fullness in the head or
headache. Especially when used in conjunction with the external ap-
plication of iodide of starch, he has seen it prove of striking benefit
in cases, of ecthymatous ulceration. Like iodide of potassium, it is
not borne in any quantity by some persons, while there are others who
can safely persevere with it for a considerable time.
An Anaesthetic Mixture of Dimethylacetal and Chloroform, two
volumes of the former to one of the latter, has been used at the Strass-
burg surgical clinic in a hundred and fifty cases. Fischer (" Dtsch.
Ztschr. f. Chir." ; " CtrlbL f. Chir.") says that its advantages are that
psychical excitement and muscular agitation do not occur, but the pa-
tients pass gradually into a quiet sleep ; that vomiting, and efforts at
vomiting, are not observed during the anaesthesia, and occurred after
consciousness was regained in only four cases (those of very anaemic
patients who had been allowed to drink a good deal after the opera-
tion)- and that the disappearance of the anaesthesia is very rapid, and
leaves the patient feeling comfortable, without any headache. The
mixture is recommended : 1. When gastric catarrh and vomiting are
especially to be avoided. 2. For laparotomy. 3. In cases of heart
disease. 4. In nephritis. 5. In diseases of the central nervous sys-
tem, particularly infantile paralysis and epilepsy. 6. In cases in
which untoward symptoms come on during chloroform anaesthesia
and the operation can be completed only with the aid of an anaes-
thetic. The drawbacks are the slowness with which anaesthesia is
induced in robust, muscular individuals, and the high price of dimethyl-
acetal.
The External Use of Chloral for Night - Sweats. — Nicolai
("Wratsch"; "St. Petersb. med. Woch.") remarks that the usual
remedies for night-sweats have the disadvantage that the system soon
becomes accustomed to their action, and that, consequently, the dose
has to be so increased that unpleasant collateral effects are produced.
The external use of chloral, he says, is free from this objection. He
uses a mixture of two drachms of chloral and two beerglassfuls of
equal parts of brandy and water. With this mixture the patient is
bathed at bedtime. If this is not enough, a clean night-shirt is put on
which has been soaked in the solution and then dried. This treatment
is said to be particularly successful with children when the trouble is
not due to phthisis.
THE NEW YORK MEDICAL JOURNAL, July 18, 1885.
LECTUKES ON
ELECTRICITY IN MEDICINE,
DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI-
VERSITY OF VERMONT, BURLINGTON,
By AMBROSE L. RANNEY, M. D., New York.
(Continued from page 32.)
THE CARE OF A BATTERY.
The best battery is liable to get out of order. It is an
easy matter, as a rule, to correct the trouble if the construc-
tion of the apparatus is thoroughly understood. The follow-
ing hints may aid the reader in obtaining a satisfactory cur-
rent with a minimum expense :
1. Keep yoxir battery clean and bright in all its parts.
Close the case when the battery is not in use, and thus keep
out dust, grease, and moisture. Emery-paper is useful to
keep the metal connections free from rust. Remember that
dirt, grease, or rust will often arrest the action of any bat-
tery.
2. When the battery fails to act properly, examine the
cells first and see if the fluid requires renewal. The " red-
acid fluid " is easily made by adding one part of commercial
sulphuric acid to ten parts of cold water ; when cooled, one
part of finely pulverized bichromate of potassium should be
added and mixed well. This is the fluid commonly em-
ployed in portable batteries with cells of the Grenet pat-
tern.
3. If the fluid is found to be fresh, and if the zinc and
carbon elements are in good order and the zinc well amal-
gamated, examine carefully all the screws and other connec-
tions attached to the elements and see if they have become
oxidized. Sometimes they become rusted or so covered
with accumulated dirt as to render the passage of the cur-
rent impossible. Occasionally the carbons may be discon-
nected and baked in an oven to render a Grenet cell more
active. Soaking the elements (in situ) in hot water which
does not reach the connections will generally suffice to
cleanse them.
4. If the cell has become polarized when in action (by
bubbles of hydrogen which accumulate upon the carbon and
of oxygen upon the zinc element), lifting the zinc out of the
fluid and replacing it immediately will suffice to overcome
this trouble if the cells are of the Grenet pattern. These
bubbles of hydrogen and oxygen set up a counter-current in
the cell which will weaken and may even neutralize the
original current.
5. Examine the interrupter, the buttons of the current-
selector, and the commutator for rust or dirt, and clean each
thoroughly when the trouble appears not to be due to the
elements or their immediate connections.
6. If a drip-cup is furnished with a faradaic or galvanic
battery, be careful to place the zinc element in it when the
battery is not in use.
7. In portable galvanic batteries, be sure to place the
rubber-covered diaphragm over the cells before closing the
case and to screw it down tightly. This prevents the fumes
rising and oxidizing the connections of the elements when
not in use. This does not apply to a red-acid battery when
not being transported.
8. Be sure that the rheophores are perfect before they are
used upon a patient. The wire used in their manufacture
is liable to become broken or oxidized by use. This is
especially true of the flexible, cotton-covered cords generally
furnished with batteries. The electrodes may be tested by
employing a galvanometer, if an imperfection is suspected
and can not be found.
9. The wires that run from the cups to the buttons of
the current-selector or the commutator may be seen on the
bottom side of the key-board of a battery. They can be
examined for imperfections when the other parts of the ap-
paratus appear to be perfect.
1 0. Do not short-circuit a battery. By this we mean, do
not allow a battery to run down, or, more technically, " polar-
ize," by the poles being brought into contact without an
interposed body (such as animal tissue) for any length of
time. For example, galvanic cells which have a low internal
resistance (as a Grenet cell) become polarized in a few hours
when the poles are connected by a short wire which affords
little if any resistance to the current.
11. Keep your electrodes clean. It is well to cover them
with fresh canton-flannel for every patient. This is an act
of precaution which will impress people with your regard
for their feelings and for their safety from contact with in-
fectious matter. Sponges are too expensive to be renewed
so often. Absorbent cotton may often be placed between
the electrode and its covering with advantage.
Part II.
The Principles of Electro-Diagnosis.*
The various electric tests that are employed as aids in
the diagnosis of nervous affections are too complex to be
fully described and explained without entering somewhat
into the domain of physics and physiology. Erbf has
lately written an excellent work upon the subject, and
most of the later treatises upon physiology will afford you
general information respecting the reactions of healthy mus-
cle to the faradaic and galvanic currents. The few practical
hints which are given here are offered with an apology for
their incompleteness, although it is hoped that they will
assist you in your studies in this field.
Having first moistened the electrodes and connected
them with the battery in action, it is customary to hold
them both in one hand (close together, but not in contact),
and apply them to the ball of the thumb of the opposite
hand or the cheek to see if the current is passing properly.
If the current to be employed is a very weak one, touch the
electrodes to the tip of the tongue before it is used upon
the patient.
Next, sponge the part of the patient's body to be tested
with a tveak solution of table-salt in warm water, in order to
* Portions of (his lecture have already been published,
f "Handbook of Electro-Therapeutics," New York, 1883.
58
RANNEY: LECTURES ON
ELECTRICITY IN MEDICINE. [N. Y. Med. Jouk.,
render the skin a good conductor of the electric currents.
If the wire-brush is to be used, this step is omitted.
The "polar method " is the one commonly used. Apply
one electrode of large size, either over the breast-bone of
the patient (at about its center) or over the back of the
neck. The breast-bone is the preferable point on account
of the absence of muscles in the median line.* The other
electrode (of small size) is placed over some special nerve-
trunk or the muscle to be tested ; in case muscle is to be
tested, the electrode is placed usually at the point where
the motor nerve enters its substance — the so-called " motor-
point" of the muscle. In this way the action of the two
poles can be readily distinguished.
In my work, "The Applied Anatomy of the Nervous
System," I have reproduced von Ziemssen's cuts, illustrat-
ing the situation of the motor-points of the various mus-
cles. In case the interrupted or faradaic current is to be
employed, the " polar method " need not be strictly adhered
to, as it is decidedly more painful than when the electrodes
are less widely separated.
Use both the continuous or galvanic current and the
interrupted or faradaic current in testing muscular reactions.
The former is of the greatest value in diagnosis.
In studying the muscular reactions to the different cur-
rents employed, remember (1) that the negative pole is
called the cathode (C),f and the positive pole the anode
(A) ; (2) that muscular contractions occur both when the
current is altered in strength and when the circuit is closed
or opened ; (3) that the faradaic current produces an appa-
rently continuous muscular contraction, because its inter-
ruptions are so very rapid ; (4) that very weak currents do
not produce contractions ; (5) that alterations in the strength
of the current cause proportionate variations in the contrac
tions ; (6) that the contractions are short, sharp, and sud-
den in health ; (7) that the effects of applying the electrode
over the substance of the muscle and over its motor-point
are identical in health, but not in some diseased conditions ;
(8) that the galvanic current will not usually produce mus-
cular contractions while it is constant, but only when its
strength is modified or when the circuit is closed or broken;
(9) that the direction of the current can be changed, with-
out altering the position of the electrodes, by a simple appa-
ratus that changes the cathode into the anode, and vice versa
(the commutator).
The current passes always from the anode to the cathode.
Hence, when the positive pole is placed on the breast or
neck, and the other on the muscle to be tested, we have a
descending current. An ascending current exists if the anode
is on the same distant or neutral point.
An " automatic interrupter " on an " interrupting elec-
trode " is necessary in employing the galvanic current in
testing muscular reactions.
* This is known as the " indifferent point," when polar effects are
being studied at the other electrode.
\ German authors employ different symbols from those given.
These are as follows : C. C. C. = Ka S. Z., C. 0. C. = Ka 0. Z., A. C.
C. = An S. Z., A. 0. C. = An 0. Z. The symbols Ka = cathode, An
= anode, S = closure (ScMiesmng), 0 = opening (Oeffnung), Z = con-
traction (Zuckung).
The descending current, when closed and again broken,
can thus give us :
1. The cathodal closure contraction :
C. C. C. or Ka S. Z. of the Germans.
2. The cathodal opening contraction :
C. O. C. or Ka O. Z. of the Germans.
The ascending current, when closed and again broken,
can give us :
1. The anodal closure contraction :
A. C. C. or An S. Z. of the Germans.
2. The anodal opening contraction :
A. O. C. or An 0. Z. of the Germans.
These four forms of contraction require currents of
different strengths to produce them. They are, therefore,
induced by gradually increasing the number of cells em-
ployed. The following order is the one commonly observed
in healthy muscle :
1 C. C. C. = Ka S. Z.
2 A. C. C. = An S. Z.
3 A. O. C. = An O. Z.
4 C. O. C. = Ka O. Z.
It will be observed that the cathodal contractions appear
first and last in health, while the anodal contractions follow
each other ; also, that the closure contractions precede the
opening contractions of both the cathode and anode. When
a nerve-trunk is stimulated by electric currents the formula
of the normal muscular contractions is altered. This will
be spoken of hereafter.
As the strength of the current is gradually increased,
the contractions which have successively appeared become
intensified proportionately (as is shown below), and new
reactions are added :
First stage {moderate current), C. C. C.
Second stage [stronger current), C C C and A. C. C.
Third stage [still stronger current), C." C." C." and A.'
C C and A. O. C.
Fourth stage [very strong current), CV" C" C" and A."
C." C." and A.' O.' C and C. O. C.
C" C" C" is called " cathodal tetanus" because the
contraction is very violent. Sometimes the anodal con-
tractions both occur with the same intensity of current,
thus merging the second and third stages into one.
Again, A. 0. C. may in some cases appear before A.
C. C.
Disease of the nerve-centers or of the nerves themselves
may cause modifications of the normal formula of muscular
contractions. This constitutes the key-note to the value of
electric currents in diagnosis. Mechanical devices may be
employed to trace the muscular contractions, as the sphyg-
mograph does the pulse. (Fig. 32.)
If the destructive process is within the brain or spinal
cord, and situated above the " trophic centers " of the nerves
supplying the paralyzed muscles, the electrical reactions of
the paralyzed muscles will be normal in respect to the se-
quence and character of the muscular contractions. Some-
times, however, a mttch stronger current (galvanic or fara-
daic) is required to produce them than over the healthy
July 18, 1885.]
RAN NET: LECTURES ON ELECTRICITY IN MEDICINE.
59
■•
L
is A
i
" ' ' " • ; ./>
; ; ' J j;
Ka
An ■
Ka.. , An
Ka.
Ka .An '
; Ka. An
. j
7 ■
' ■ V
. Art ; .:. •••
An
.-1)1
muscles. This fact is due to atrophic changes in the mus- | contractions, irrespective of the strength of the current em-
cles. It may be of decided value in diagnosis. ployed.
When disease processes in the brain or spinal cord cause I Finally, in unilateral paralysis the electrical reactions of
the muscles of the paralyzed side should
be contrasted with those of homologous
muscles of the unaffected side. When
both sides are impaired, the standard of
comparison should be that of a healthy
subject of about the same size, weight,
and muscular development.
Now let us suppose that we wish to
test the reaction of some special nerve —
the musculo-spiral, for example. \\ e
place the positive pole (An) of a gal-
vanic battery over the breast-bone with a
large flat electrode attached, and the
negative pole (Ka) over the nerve (where
it winds around the humerus below the
deltoid muscle) with an "interrupting"
small electrode attached to the nega-
tive rheophore. We then put into cir-
cuit a few cells at a time and press the
button of the interrupting electrode at
intervals till we get a contraction of mus-
cles. When the current is sufficiently
strong to excite the nerve-trunk, contrac-
tion of the extensor muscles of the forearm becomes ap-
parent (the cathodal closure contraction^. Thus we ascer-
tain the number of cells required to produce C. C. C.
(Ka S. Z. of the Germans). Now add a few more cells,
and reverse the poles by means of the commutator. When
the circuit is broken, by releasing the button of the inter-
rupting electrode, we get the anodal opening contraction
(A. 0. C, or An O. Z.), and, with a few more cells, the
anodal closure contraction (A. C. C, or An S. Z.). Again
reverse the current, and add a few more cells. Now, on
pressing the button of the interrupting electrode, we get a
very intense cathodal closure contraction (C"\ C-". C'".,
or Ka S. 21".), and, on releasing it, the cathodal opening
contraction (C. O. C, or Ka O. Z.) is developed, thus com-
pleting the chain of polar nerve-reactions.
You should bear in mind that the polar nerve-reactions
differ in their normal sequence from those of the muscles
when the electrode is placed over the "motor point " of the
Fig. 32.— Curves op Closure Contractions in Direct (Unipolar) Stimulation op the Mus.
cles in the distribution of the peroneal nerve in the leg (erb). ka = c. c. c. ; an
= A. C. C. 1, Curve of health, thirty-three elements ; C. C. C. is greater than A. C. C. ; 2, case
of chronic anterior poliomyelitis, showing reaction of degeneration with thirty-three elements ;
3, same case, with forty elements. In 2 and 3, the excess of A. C. C. over C. C. C. is apparent ;
3, in the slow character of the contractions is very marked.
destruction of the trophic centers of the nerves that supply
the paralyzed muscles, or when the cerebrospinal nerves
themselves are seriously injured, we encounter what Erb has
described as the "reaction of degeneration." This will
require some explanation.
1. Every nerve degenerates when separated from its tro-
phic center ; hence, the electric excitability of the nerve,
both to the faradaic and galvanic currents, gradually dimin-
ishes and ceases entirely at the end of about two weeks.
2. The faradaic current ceases to cause muscular con-
tractions when applied directly over the substance of the
muscle. This is explained by the fact that the so-called
" nerve-plates " within the substance of the muscle are de-
generated, and currents of momentary duration fail to affect
the muscular fibers.
3. The muscular contractions produced by the galvanic
current are diminished for about ten days. Subsequently
the excitability of the muscles to slowly interrupted galvanic
currents becomes increased, so that very weak currents may mUscle tested,
excite contractions. This may disappear in five or six
months.
4. The polar reactions become altered in their sequence.
The anode contractions appear before those of the cathode,
as shown below :
1 A. C. C. instead of C. C. C. as in health.
2 C. C. C. " A. C. C. " "
3 C. 0. C. " A. 0. C. " "
4 A. O. C. " C. O. C. " "
5. The character of the muscular contractions becomes
altered. In health, they are sharp, short, and sudden.
When degeneration occurs, they arc slow to appear ; they
are prolonged and continue even during the passage of the
current ; and, finally, they assume the character of " tetanic "
NORMAL NERVE-REACTION.
C. C. C.>A. O. C>A. C. C>C. O. C.
NORMAL MUSCLE -RE ACTION.
C. C.'OA. C. C>A. O. OC. O. C.
The final contraction (C. O. C.) of each of these series
is seldom seen, because the current required to produce
it is too painful to be endured. Fewer cells are required
to cause muscular formula; than those of a nerve-trunk.
In recording the results of an electrical examination of
nerve-trunks and muscles it is best to arrange the record-
page so that the two sides of the body may be easily con-
trasted. The number of galvanic cells employed or the
number of milliamperes of current (as shown by a galvanome-
ter) should also be specified, and the faradaic reaction of
60
RANNEY: LECTURES ON ELECTRICITY IN MEDICINE. [N. Y. Med. Jocb.,
homologous nerves or muscle should be stated for the pur-
pose of comparison and for clinical deduction. We may
follow with advantage some such plan as the following:
Name Date, .... Age, ....
History of Case. See page .... of Case-Book.
Faradaic Tests.
Right side.
Left side.
Extent of sec"
ondary coil
• employed.
(In centime-
tres.)
Nerve tested.
Muscle-reactions ....
Muscle tested.
Galvanic Tests.
Right
side.
Contraction
produced.
Left side.
Nerve or
muscle
tested.
Nerve-reactions. . 1
Cells.
C. C. C.
A. 0. C.
A. C. C.
C. 0. C.
Cells or milliainperes
1
j nerve.
Muscle-reactions . -f
C. C. C.
A. C. C.
A. 0. C.
C. 0. c.
\ muscle.
Slips of this character may be printed and kept on hand.
They can be pasted into the case-book of the physician
when filled out. The tests made at different dates can thus
be compared with each other and the progress of each case
determined.
Fig. 3.3.— The Author's Spring Electrode.— D, the binding-post for attach-
ing the rheophore which connects it with the battery, or with the diagnostic
key-board when that instrument is employed. The motor point of the elec-
trode is represented as enveloped in chamois-skin. It must be thoroughly
dampened in salt-and-water before it is applied to the nerve or muscle to be
tested The other end of the electrode is designed to prevent slipping of
the instrument after its proper adjustment.
For the purpose of demonstrating the special action of
individual muscles and nerves before classes of students, as
well as the study of muscle- and nerve-reactions in disease,
I have devised small electrodes which may be made station-
ary upon any desired part of the head, limbs, or trunk, by
means of straps, strips of adhesive-plaster, or insulated
springs. By means of these I have been enabled to make
many points clear to a large audience which would be ex-
tremely difficult to show by any other method. Further-
more, it is often desirable to refer from time to time during
an examination of. a patient to the effects of currents of
known intensity upon certain nerves and muscles for the
sake of accurate comparison, etc. Small electrodes of the
type described may be accurately placed upon a patient and
allowed to remain upon the spot selected during the entire
examination. To each of these a separate rheophore may
be attached and, by a simple device of my own, each may be
controlled by touching a key upon a board, without move-
ment of the operator. I can thus observe simultaneously
the reactions of corresponding muscles or nerves upon the
Fig. 34. — The Author's Diagnostic Key-board.— A, the rheophore which
connects it with one of the binding-posts of a galvanic battery ; B, rheo-
phores connecting its binding-posts with spring electrodes previously placed
upon the body of the patient so as to influence the nerves or muscles to be
tested ; C, buttons and springs which make a circuit to the body of the
patient when the knob on the spring is pressed downward so as to impinge
upon the button. The number of rheophores which may be employed
depends upon the necessities of the case ; the cut shows an instrument
capable of six.
two sides, those of the leg and arm of the same side, and
any other comparisons which may be required in diagnosis.
The " motor-points " of the body are not always exactly
where charts depict them ; hence it is sometimes necessary
to hunt for them within a radius of an inch or two of the
normal point. When they are found with exactness, a small
electrode may be fastened over the spot (with moistened
absorbent cotton beneath it) and allowed to remain station-
ary during the entire sitting. Whenever it becomes neces-
sary to refer to the reactions of that point, it can be called
into action by touching the key connected with it by its
individual rheophore. The cuts introduced show the ar-
rangement of my device for this purpose. I have given a
more complete description of the advantages of this method
over others previously employed, in the " New York Medical
Journal" of May 9, 1885.
Now, from such a table of record it is apparent that the
faradaic current should first be employed upon the patient
(the poles of the secondary coil being used). The extent
of the overlap of this coil (in centimetres) necessary to
produce muscular contractions when the nerve- and muscle-
reactions are being separately tested should be recorded.
In case no muscular contractions ensue, the extent of the
overlap which produces an unbearably painful current should
be ascertained and noted. This may be compared with that
necessary to produce contractions upon the healthy side.
The " polar method " should be employed in the tests thus
made and recorded.
The next step in the examination consists in changing
the rheophores to the binding-posts of a galvanic battery.
We can now ascertain the number of cells or of milliam-
peres (which is preferable) required to produce the different
varieties of contractions (enumerated in the table designed
for record) of muscles in homologous regions of the right
and left sides. Each nerve which is impaired should be
tested first ; and the muscles supplied by it should be tested
afterward. The strength of the current employed should
be ascertained by throwing a galvanometer into the circuit
Jnly 18, 1885.J
RANNEY: LECTURES ON ELECTRICITY IN MEDICINE.
61
(when extreme accuracy is desired) ; by so doing, a compari-
son of the nerve- and muscle-reactions of the two sides can
be based upon conditions which are exactly alike.
Fig. 35.— The Author's Diagnostic Key-board as applied in Actual Use. The spring electrodes
are represented in the cut (for the purpose of illustration) as applied to the facial, ulnar, and musculo-
spiraf nerves of each side. If he chooses, the operator can have his case-book on a stand at his right,
for recording his observations as they are made.
AVhen we have completed the steps indicated by the
chart prepared for the assistance of the beginner we are in
possession of certain facts which may be of great practical
value as regards both diagnosis and prognosis :
1. Suppose a case of localized paralysis is examined, and
the faradaic and galvanic reactions of both a nerve and its
muscles are normal and exactly alike on the two sides. We
have reason then to believe that the exciting cause is either
hysteria, a lesion of a higher spinal segment than that from
which the nerve arises, or a lesion within the brain, pro-
vided the possibility of deception on the part of the patient
respecting his paralytic condition can be excluded.
2. If the nerve-reactions of the affected side to both
currents are exaggerated (i. e., if the contractions occur in
their proper sequence, but under a weaker current than in
health), the probability of an existing central lesion is height-
ened, although hysteria may possibly still exist as the ex-
citing cause of the paralysis.
3. If the faradaic current applied through the nerve fails
to produce contractions of the affected muscles as readily as
upon the healthy side (i. e., if a stronger current is de-
manded to call any one of the paralyzed muscles into action
indirectly through the nerve which supplies it), then we know
that the nerve filaments within the spinal cord or the trunk
of the nerve itself are affected by a lesion which has impaired
but not entirely destroyed their usefulness.
4. "If no current from a faradaic machine (which can be
endured by the patient) causes muscular contractions, we
know positively that the motor cells of the anterior horns of
that spinal .segment which controls the paralyzed muscles
are destroyed, or that the nerve itself has been severed from
its connection with the spinal cord.
5. When the muscle-reactions to the faradaic current
have been tested, the previous deduc-
tions (based on the nerve-reactions)
still hold good. The electrode should,
however, be placed over the " motor
point " of each muscle thus tested.
6. If the formula obtained by the
galvanic current are normal, all ques-
tions regarding the existence of de-
generative changes in the nerve- or the
muscle-plates can be excluded. When
the normal order is altered, degenera-
tive changes in the nerve- or the
motor-cells of the spinal cord are
present.
7. The history of a case in which
motility is impaired is never complete
without a record of an electrical ex-
amination of the nerve- and muscle-
reactions to both the faradaic and gal-
vanic current. When doubt exists
respecting the existence of a cerebral
lesion or hysteria, the facts obtained
by other methods of examination (fully .
described by me in the " Medical Rec-
ord," March, April, and June, 1884)
will clear up all doubts.
8. Patients afflicted with paralysis from a cerebral lesion
generally exhibit normal electro-nerve and electro-muscular
reactions in the paralyzed parts. In some instances the
reactions may even be exaggerated.
9. Hysterical patients afflicted with paralysis may ex-
hibit either normal or exaggerated electro-muscular reac-
tions to faradism or galvanism. The sensitiveness of the
muscles to faradism is generally decreased ; in some cases
it may be totally wanting (Duchenne).
10. In rheumatic 2Mralys*s the electro-muscular con-
tractility is, as a rule, markedly increased ; this may be
shown by a comparison of the reactions of the two sides of
the body. In exceptional cases this is not found to be so,
as I have seen the reactions follow only the strongest cur-
rents.
11. In peripheral paralysis the faradaic and galvanic
reactions are altered after ten days have elapsed. The mus-
cular contractility to the faradaic current is lost earl} to a
greater or less extent ; and the formula of degenerative
changes is developed later by the employment of the gal-
vanic current.
12. A decreased musculo-exeitability to the faradaic
current in the musculo-spiral nerve and the extensor mus-
cles of the forearm on both sides — the flexors being normal
and the lower extremities being unaffected — tells us of the
approach of lead-poisoning before the actual symptoms are
well marked.
13. In progressive muscular atrophy a response to the
faradaic current can be obtained as long as any filters in tlie
muscle tested remain free from fatty metamorphosis.
RANNEY: LECTURES ON ELECTRICITY IN MEDICINE.
[N. Y. Meu. JorR.,
14. No alterations in the electro-contractility of muscles
is observed in any of the diseases confined to the posterior
part of the spinal cord.
DETECTION OF FEIGNED DISEASES.
In addition to the uses of electricity for the purpose of
determining the presence or absence of nerve- and muscle-
degeneration, and the discrimination between cerebral and
spinal paralysis and the various types of peripheral palsies,
some other useful purposes in diagnosis have been published
from time to time.
The Detection of Death. — It is stated that muscular con-
tractions produced by the faradaic current can not be main-
tained over four hours in a dead subject.
Malingerers are not uncommon among the applicants
for charitable aid, and they are occasionally encountered
among the higher walks of life. Epilepsy and paralysis are
the most common diseases which are feigned.
Feigned epilepsy can be distinguished by the application
of a strong faradaic current to the forehead or tibia by
means of a wire-brush. The intense pain so produced will
not be appreciated by a true epileptic, but will bring the fit
to a sudden close, if assumed in order to create sympathy
or aid.
Feigned motor paralysis is usually exhibited in some of
the various forms of peripheral paralysis. Few malingerers
know enough to simulate hemiplegia or paraplegia without
detection. If two weeks have elapsed since the attack, the
presence of normal electrical reactions of nerve and muscle
in the affected limb is strong ground for suspicion, pro-
vided a history of some cerebral lesion or of hysteria can
not be elicited. There are various other tests which a
skilled anatomist can employ in each case that will help to
clear up all doubts upon this subject.
Feigned anesthesia may be told by the use of the fara-
daic current with the wire-brush attached to the negative
rheophore. The opposed limbs will quickly show how
much actual anaesthesia exists.
Detection of Bullets or Buried Metal. — An ingen,
ious application of electricity to surgery has been made
which has utility in diagnosis.
The so-called " electric probe " consists of two wires
which are perfectly insulated from each other by rubber or
ivory. These wires terminate in metal tips which project
slightly beyond the insulating medium, and at the other
end of the wires a galvanic cell and an electro-magnet act-
ing upon a bell are attached. When the probe is pushed
into the tract made by a metallic missile, and the tips are
brought into contact with it, the circuit is completed and
the bell rings. The animal tissues are not sufficiently good
conductors of electricity to form a circuit; hence the bell
will not ring until the metal is touched by the tips of the
probe.
Electro-diagnosis of Aural Diseases. — We owe to
Brenner, of St. Petersburg, the first suggestions of this use
for electric currents in diagnosis. From a somewhat limited
experience in its use, I am led to believe that its utility can
not longer be called into question. Brenner's formula
seems, furthermore, to be in accord with all that has been
proved in respect to nerve-trunks in health, in all parts of
the body. The formula is simply that of the galvanic reac-
tions of the auditory nerve in health.
1. In place of the C. C. C. observed in muscle, we get,
when a galvanic current is sent through the auditory nerve, a
ringing noise when the cathodal closure occurs. (C. C. S.)
2. The cathodal opening produces no effect.
3. The anodal opening produces a ringing noise when a
current of high intensity is employed.
4. After the cathodal closure {cathodal duration — C. D.),
the ringing noise produced at the closure gradually dimin-
ishes. . •
The formula which is indicative of health when a pole
is connected with each ear may be expressed in symbols, as
follows :
Right Ear (Anode). Left Ear (Cathode).
C. (closure) .... S. (loud)
O. (opening)... . S. (weak)
D. (duration) S. >
Now, it is maintained by Brenner that any deviation
from the normal reactions of the auditory nerve (shown in
the preceding formula) indicates disease of the acoustic
mechanism. The variations produced by the different dis-
eased conditions encountered can not be given here from
want of space.
In applying galvanic currents to the ear, it is best to
place a medium-sized electrode over the entire tragus, or to
fill the external auditory canal of the ear to be tested with
tepid water containing a little salt, and then to introduce an
electrode of metal inclosed in an aural speculum of hard
rubber into the ear until the metal touches the water. If
each ear is to be tested separately, the other electrode should
be placed at an indifferent point, preferably the mastoid
region of the same side or the middle of the sternum.
Regarding this test, it is well to state that repeated sit-
tings are often necessary. The patient has to become accus-
tomed to the disagreeable effects of the current. It is de-
sirable that you begin with very weak currents and increase
the strength very gradually. As the reaction of cathodal
closure (C. C.) is the most important," it can be intensified
by previously allowing cathodal duration (C. D.) to act, or
by rapidly following C. C. by A. O.
Examination of the Eve, Nose, and Mouth by Elec-
tricity.— Special effects are produced upon the organs of
sight, smell, and taste by electric currents. Sparks or vivid
Hashes of light follow electric stimulation of the eye; and
subjective odors and tastes are also produced when the ol-
factory and gustatory nerves are excited by this agent. The
"polar method" of examination is employed when any of
the special senses are thus tested. I would caution each of
you against employing too strong currents about any of the
organs of special sense. The examination of the optic, ol-
factory, and gustatory nerves recpiires experience and should
not be attempted by novices.
When examining the reactions of the eye, the small elec-
trode is placed upon the closed eyelid, temple, or forehead.
The large electrode is placed upon the back of the neck.
The room should be darkened and the patient should keep
both eyes closed.
July 18, 1885.]
When iesting the sense of taste, the poles should be in
contact with the cheeks, and the sensations of taste experi-
enced upon both sides by the patient should be ascertained.
A fine electrode can also be placed upon the tongue, the
pharynx, or the inside of the cheek, in case localized polar
reactions are to be determined. A double electrode, with
two metal tips which are not in contact, may be employed
for this purpose (Neumann).
Electrical Examination of the Sensibility of the
Skin. — The electrode devised by Erb is to my mind the
best for this purpose. It consists of four hundred varnished
wires in a tube of hard rubber. The ends of these wires
make a perfectly smooth surface. This electrode is con-
nected with the secondary coil of a faradaic machine and is
then pressed upon the area of the body to be tested — the
other pole being at the sternum. The minimum of the
overlap of the secondary coil which can be felt and the
maximum which can be endured are both recorded. Ho-
mologous parts of each side should be compared with each
other.
Fig. 36.— Erb's Electrode tor the Examination op Farado-cutaneous
Sensibility, a, a hard-rubber tube ; b, the free surface of the electrode.
Regarding this test Erb wisely remarks : " The skin,
regarded as a sensory organ, can not be tested with irritants
other than those adequate to it — viz., touch, pressure, vari-
ous temperatures, and the higher grades of those irritants
which produce pain. It may be disputed whether electric-
ity should be included among these ' adequate ' irritants of
the skin. The electric sensation is a specific, distinct qual-
ity of tegumentary sensibility, whose careful examination,
however, is of value in many morbid conditions."
flPrigural Communications.
ANTISEPTIC INHALATIONS*
By BEVERLEY ROBINSON, M. D.
In a paper read before the Practitioners' Society of
New York last winter, " On the Utility of Intra-pulmonary
Injections in the Treatment of Pulmonary Phthisis," I said
* Read before the American Climatological Association, May 27,
1885.
63
that I intended, at an early date to bring before my medi-
cal colleagues the subject of antiseptic inhalations. In the
brief paper I now offer for your consideration I shall do
this, but I shall not limit myself solely to the consideration
of the advantages of these inhalations in pulmonary phthisis.
Already I have made use of them in several affections of
the respiratory tract — both acute and chronic. Although
the cases treated by me in this manner are not yet numer-
ous enough to afford a solid basis for final conclusions, they
are at least sufficient to point distinctly to an extensive and
beneficial trial of this method in a large class of respiratory
diseases. The method is not new, it is old ; but it is also a
case of revival, with more precise data to establish its spe-
cial indications and employment. To any one who has
made frequent use of steam vapor inhalations, and hot or
cold atomized fluids or sprays, the great advantages of the
plan which forms the theme of this study, in the treatment
of the affections referred to, is too real to be lightly con-
sidered or entirely ignored.
In its favor may be cited the following propositions :
1. The apparatus required costs but a trifle, and may be
used, therefore, even by the poorest classes.
2. Medication thus apjjlied may be employed under cir-
cumstances where the use of hot or cold sprays is imprac-
ticable.
3. There are no risks of future colds attendant upon its
employment.
4. The relief afforded by dry vapor inhalations is, in my
experience, frequently greater than that given by the other
methods of inhalation.
5. This medication is well adapted to all forms of irrita-
tive disease of the respiratory passages.
I know of only one serious objection which can be prop-
erly urged against its very general adoption, and it is the
statement that the vapors of volatile antiseptic substances,
when they are employed in the ordinary oro-nasal inhaler,
do not penetrate far enough to reach the pulmonary cells,
and, therefore, can not possibly modify this structure in
any sensible degree.
Upon experimental grounds, Arthur Hill Hassall (" Lan-
cet," May 5, 1883) has endeavored to show that the agents
most frequently employed hitherto — such as carbolic acid,
creasote, thymol, etc. — are but feebly volatile at ordinary
temperatures. He has also been unable, after prolonged
inhalation, to recover any notable quantity of these sub-
stances in the sputa or secretions from the air-tract. In
fact, he has not even remarked that the sputa, soon after
they were expectorated, were penetrated with their odor.
Indeed, after continuous inhalations of one or two hours'
duration, he has succeeded in obtaining, by Chandelon'a
process, from the sponge or cotton in the inhaler, very
nearly the whole quantity of the agent employed. A
sufficient answer to these objections, it seems to me, may
be found in the fact that the patients themselves, when
questioned, after they have used the inhalations dur-
ing a few days or weeks, as to their utility, almost in-
variably reply that their subjective symptoms have been
notably relieved by them. Not only do they make this
statement, but they add, further, that their sputa have di-
ROBWSON: ANTISEr I IG INHALATIONS.
64
ROBINSON: ANTISEPTIC INHALATIONS.
[N. Y. Med. Joce.,
minished in quantity, and at times have notably changed in
appearance. Moreover, while I am willing to admit that
dry vapors do not enter the lungs so deeply as we might
presume, or indeed as, theoretically, we might desire, yet
they certainly do go further than the sprays for which they
have been substituted. I am of the opinion, also, that the
small loss of substance which has not been recovered, and
which possibly does penetrate the pulmonary air-cells, is
sufficient to modify notably, after several days or weeks of
more or less continuous inhalation, the inspired air in such
a manner that it is made comparatively aseptic, and thus we
have an influence for good that we can properly estimate
only by the evident effects produced. In regard to the
areas of cough in the bronchial tubes, as in the lung itself,
I believe something may be learned by reference, first, to
my own experiments with intra-pulmonary injections, and,
second, to the well-known facts recorded by Hack and J. N.
Mackenzie in their investigations upon the nasal passages.
In my experiments I was led to believe that pulmonary
cough was largely due to irritation produced at the apices.
And surely this conviction need not be a matter of surprise,
since we all know that the sensitive area for cough in an-
other organ (the nose), physiologically allied to the lungs,
is not general, but limited almost to the posterior extremi-
ties of the turbinated bodies.
Again, is it not true that, in many cases where there is
notable effusion into the air-cells at the pulmonary bases, as
in oedema following chronic Bright's disease or organic
heart disorders, there is usually little or no cough ? When-
ever, on the contrary, as in commencing bronchitis or
phthisical infiltration, there are obvious morbid changes at
the apices, what more obstinate and constant symptom can
be observed than the ceaseless racking cough ? Finally, I
have on more than one occasion, I am confident, punctured
the lung deeply in searching for pleuritic fluid, either pos-
teriorly or in the axillary line, as was evident by the blood
and air withdrawn into the cylinder of the hypodermic
syringe, or into the pump of the aspirator, and cough has
not followed invariably. This fact is, however, also true in
regard to punctures at the pulmonary apices; but here the
intra-pulmonary alterations have been very different from
what existed at the bases at the time punctures were there
made. In the former cases the lungs were already infil-
trated with tubercles which blocked up the bronchi and
surrounded their periphery ; in the latter cases the bron-
chial tubes were inflamed or compressed, it is true, but
were not, as a rule, completely impervious to air. Mucus
and serum, blood-streaked or not, they usually contained,
no doubt, but even then their condition was such as to
render them a priori more sensitive than they should be
under wholly normal circumstances.
I will now place before you some of the results of my
trials with dry vapor inhalations up to the present time, and
if, by their analysis, I can prove the utility of this method
clinically, I shall hope to stimulate further inquiry, and per-
suade many of you to give it the opportunity which, I be-
lieve, it merits. It is understood, I assume, that I do not
claim any originality for the treatment of my cases. These
dry inhalations were reintroduced to the profession, as you
are all aware, some years ago by Dr. W. Roberts, of Man-
chester, England, and since that time have been more or
less extensively employed by H. Curschmann, of Hamburg,
and by several other able practitioners at home and abroad.
Among these I would cite particularly William Pepper, in
the "Transactions of the American Medical Association"
for 1880; J. H. Tyndale, New York "Medical Record,"
March 18, 1882 ; J. Barney Yeo, in his " Lectures on Con-
sumption," London, 1882; S. S. Cohen, in Philadelphia
" Medical News," October 11, 1 884 ; J. Ward Cousins, " Lan-
cet," July 19, 1884; and A. Hill Hassall, " Lancet," August
16, 1884, and "Inhalation Treatment," London, 1885. .
The following summary shows the number and nature of
the cases of which I have preserved notes, but does not
represent one half the number of patients for whom I have
ordered oro-nasal inhalers. I regret to add that, even in those
cases of which I possess a record, several were not studied
with much care, and, consequently, my remembrance of the
results obtained is very imperfect. A sufficient number
remain, fortunately, in which I have watched carefully the
effects of dry inhalations, and about whose condition, before
and after their use, I can speak with more assurance.
My tabular statement includes twenty-two cases of
phthisis pulmonalis, catarrhal or tubercular, at its first stage,
or when already there were evident and characteristic signs
of tissue infiltration.
In four of these cases there were marked local pleuritic
adhesions. In the remaining cases no statement is made
other than the fact that pulmonary consolidation at the
apex or apices was present.
Nineteen cases of pulmonary phthisis, catarrhal or tu-
bercular, at its second stage, were treated partly by means
of oro-nasal inhalers. Of these nineteen cases, in eleven the
softening was limited to one apex ; in two cases both apices
were thus affected, while in the other cases no reference is
made to the limitations of the disease. There were six
cases of fibroid- phthisis treated by inhalers; three cases of
laryngeal phthisis, in one of which there was commencing
carious ulceration of the vocal cords. There were two
cases of acute laryngitis, seven cases of subacute laryngitis,
three cases of chronic laryngitis, two cases of subacute
bronchitis, three cases of chronic bronchitis, five cases of
chronic nasal catarrh, four of which were of the hypertro-
phic form, the remaining one being distinctly atrophic ca-
tarrh, with which were connected a condition of pharyn-
gitis sicca and a notable degree of foetid odor of the breath
(ozaena). I also treated in this manner one case of chronic
pharyngitis, two cases of localized pleuritis, and one of
paralysis of the tensors of the vocal cords — the total mak-
ing seventy-six cases which form the basis of the remarks I
shall make before you to-day.
First, in regard to pulmonary phthisis at its first stage.
Of this disease I have the records of twenty-two ca>es in
which I used dry vapors. The inhalations consisted of, 1,
creasote and alcohol equal parts; 2, creasote one part, ol.
pini sylvestris two parts, and compound tincture of benzoin
eight parts ; 3, compound tincture of benzoin ; 4, fir-wood
oil ; 5, fir-wood oil sixteen parts, creasote one part ; 6, fir-
wood oil six parts, chloroform two parts; 7, creasote one
July 18, 1885.] GRAY: TWO VALUABLE AIDS
TO ELECTRO-THERAPEUTICS.
65
part, fir-wood oil sixteen parts ; 8, compound tincture of
benzoin and fir-wood oil, equal parts ; 9, spirits of turpen-
tine; 10, volatile oil of eucalyptus; 11, carbolic acid and
tincture of iodine, of each one part, compound tincture of
benzoin eight parts; 12, fir-wood oil one part, succus conii
and compound tincture of benzoin, of each two parts, car-
bonate of magnesium, q. s., water eight parts ; 13, pine-nee-
dle oil; 14, terebene four parts, spirits of chloroform one
part.
It will be remarked that I varied considerably the
nature and composition of the substances employed for in-
halations— and this is specially notable if the limited num-
ber of my cases be considered. I made these trials ad-
visedly, as I was very desirous to find out not only if* vapor
inhalations were useful, but, indeed, if certain combinations
were more effective than others under similar conditions.
The results of my observations would seem to show that
the most generally useful inhalation in the beginning of pul-
monary phthisis is creasote and alcohol, equal parts. Crea-
sote by itself is a little too irritant, and is not so readily ma-
nipulated. Whether or not the mixture of alcohol increases
its volatility I am not positive, although I believe it does,
regard being paid to the statements of patients. The
amount of inhaling fluid employed with best results varied
from ten to twenty drops. It was also renewed most ad-
vantageously two or three times in twenty-four hours. The
inhalations were employed at first about ten minutes every
two, three, or four hours. After a week or two they could
be continued, without unpleasant effects, one half or one
hour at a time, and repeated three or four times in twenty-
four hours. If a larger quantity of the inhaling fluid was
used at first on the sponge of the inhaler, or if at first the
time for each inhalation was extended beyond fifteen min-
utes, the patient suffered from irritation of the throat and
increased painful cough on several occasions. The form of
inhaler employed by me was usually one not dissimilar in
outward conformation to that employed by Burney Yeo, of
London, and S. S. Cohen, of Philadelphia. It may be of
interest in this connection to give a short account of the
different oro-nasal inhalers in use at the present time. Some
of these are shaped so as to cover the mouth alone, some
are adapted simply to inhalation through the nose, and
some encircle both nose and mouth. They are made of
metal, hard rubber, or celluloid, and are usually constructed
from a single sheet of the material employed, their particu-
lar shape being made to suit the requirements of the major-
ity of individuals. In Blake's and Tyndale's inhalers, which
cover both nose and mouth, there is a circular valvular
opening on either side, about one third of an inch in diame-
ter, which closes by means of a soft rubber flap that rises or
falls with each inspiration or expiration, and is intended to
promote the facility of expiration and to avoid the passage
of respired air through the sponge charged with the inhal-
ing fluid. In llassall's oro-nasal globe inhaler similar val-
vular openings on the sides have been provided, and this
inhaler has the additional advantage, as stated by its in-
ventor, of supplying a larger amount of medicated vapor to
the patient for purposes of inhalation. This result is effect-
ed by reason of the considerable capacity of the globe itself
for containing bits of lint moistened with a suitable amount
of inhaling fluid, and owing to the wider orifice of commu-
nication between the globe and the oro-nasal piece, or shield,
which allows plenty of medicated vapor to pass through and
be inhaled with each inspiration. When an inhaler is fitted
to the nose alone, it is better, as a rule, for the patient to ex-
pire through the mouth than through the nose, as in this
way a more complete circuit of the nasal passages by the
vapor is accomplished than if expiration took place through
the nose. None of the inhalers described, although some-
what more elaborate and expensive, seem to me so useful as
the cheap and simple one here shown. This one, as you
perceive, is made of a thin sheet of perforated zinc ; it is ex-
tremely light, and may be worn, therefore, a long time with-
out causing the fatigue to the patient which the other inhal-
ers often do. It also permits the air to pass freely in and
out, and thus obviates almost entirely the sensation of oppres-
sion and stifling, which is apt to make the prolonged use of
the other oro-nasal inhalers almost impossible.
One of the objections urged against the efficacy^ of most
oro-nasal inhalers, is the fact that too small a supply of vapor
is given off from the small bit of sponge, cotton, or tow
which comes with them to be of any benefit to the patient.
In the globe inhaler Dr. Hassall has remedied this supposed
defect. For my part, I have not usually found it a defect,
and I have rarely found the slightest difficulty in supplying
my patients, by means of the perforated zinc inhaler, with all
the medicated vapor they could comfortably endure. In-
deed, I have observed several times, as other observers have
done before me, that the quantity of antiseptic liquid added
to the sponge of the inhaler must be limited to a few drops
(10 to 20) if the inhaler is worn more than a short time.
If a relatively large quantity of antiseptic fluid be added to
the sponge, the vapors proceeding from it are too concen-
trated and shortly become very irritating to the air-passages,
and the inhaler must be abandoned. Instead of doing good,
therefore, by adopting the latter manner of medicating the
sponge of the inhaler, we actually do harm and render a
very serviceable agent a decidedly objectionable one. I am
therefore not of the opinion of Dr. Hassall as regards this
point in inhalation— viz., that with the ordinary forms of
oro-nasal inhalers we do not volatilize a sufficient quantity
of antiseptic fluid to be of service as an inhalant ; and even
when we volatilize enough fluid not enough antiseptic va-
por is inhaled to modify the air-cells to any notable de-
gree.
(To be concluded.)
TWO VALUABLE AIDS TO
ELECTKO-THEE A PEUTICS.
By LANDON CARTER GRAY, M. D.,
PROFESSOR OF NERVOUS AND MENTAL DISEASE, NEW YORK POLYCLINIC : AT-
TENDING PHYSICIAN TO ST. MART'S HOSPITAL : ATTENDING PHYSICIAN TO
THE HOSPITAL FOR NERVOUS AND MENTAL DISEASE.
One of the greatest of the difficulties that have been
encountered by the electro-therapeutist has been the lack of
a suitable galvanic battery. Of good faradaic machines
there has been no dearth, especially since the invention of
the cheap and portable apparatus made by Gaiffe, of Paris.
66
GRAY: TWO VALUABLE AIDS TO ELECTRO-THERAPEUTICS. [N. Y. Med. Jooh.,
But the galvanic batteries for general use have been un-
pleasantly heavy, and the Grenet cell, or some modification
of it, which has been mostly employed in them, is a con-
stant source of annoyance from the necessity of frequent
renewal of the plates and still more frequent renewal of
the fluid. I have therefore, for years, been on the search
for some combination of elements that would be portable
and durable in a far greater degree than the Grenet cell.
My attention was called to the fact that Gaiffe was con-
structing a battery with the chloride-of-silver elements that
seemed to answer the requirements ; but the importation
was costly and troublesome, and the cells had to be sent to
Paris for renewal. Dr. De Watteville, of London, very
kindly put me in communication with Mr. Schoth, an instru-
ment-maker of London, who had been experimenting with
the same cells at Dr. De Watteville's instance ; but Mr.
Schoth had not yet constructed a battery with them. Finally
I ascertained that Mr. John A. Barrett, a New York elec-
trician, was making a battery with these cells. This instru-
ment I have now been using daily for some five months, and
I am prepared to say that its general employment will
mark a new era in galvano-therapy. The cut (Fig. 1) gives
Fig. i.
some idea of the size of the battery, but a better one can
be obtained from the statement that an instrument contain-
ing thirty-two cells will only measure ten inches in length
and weigh only nine pounds, while a fifty-cell one will
measure twelve and a half inches and weigh twelve pounds.
As will be perceived by electro-therapeutists, such a bat-
tery is by all odds the lightest that has yet been con-
structed. As to its durability, it is calculated that each
cell will stand two hours' steady work daily for nine months,
or a proportionate length of time otherwise arranged, be-
fore the elements will need renewal. Practically, therefore,
such a cell will last the general practitioner a year or
more, and the cost of renewal will be about eight dollars.
The details of construction are as follows: The cells con-
sist of cylindrical bottles of black rubber. These bottles arc
fitted with screw stoppers or caps of the same material, which
are fastened permanently to the underside of a black rubber
plate. The elements, zinc and chloride of silver, are fast-
ened to silver wires which pass in pairs up through suitable
perforations in the caps and plate, and are attached on the
• 1
Fig. 2.
upper surface of the plate to fixed studs or pins so arranged
that the zinc and silver poles of the successive cells are con-
nected together through the entire battery. The bottles
Fig. 3.
are partly filled with solution and are screwed from under-
neath to the caps, each bottle inclosing a pair of elements.
The bottom of each bottle is provided with a slot, so that by
a key the bottles may be screwed tightly to their caps. By
this means the entire set of bottles is rigidly attached in
an upright position to the plate, and at the same time any
bottle may be removed independently of the others and its
pair of elements examined, or removed and replaced, without
inconvenience. Besides this, all the connections, being on
the upper side of the plate, are easy of access and out of the
reach of corrosion. The battery, thus prepared, is placed in a
box, and a top-plate, perforated to fit the connecting studs, is
laid over it. This top-plate is numbered for convenience in
making connections. It is easily removable, and the whole
battery may be readily lifted out of the box. In the lid of the
box is placed a commutator or pole-changer, to which are at-
tached short flexible cords terminating in hollow plugs. By
these plugs any number of cells may be selected from any
part of the battery. The pole-changer is also provided with
two binding-posts, to which the conducting cords are to be
attached. In the lid of the box are also springs for holding
a pair of electrodes and handles. The strength of the
battery is very nearly equal — within — to the same
number of Daniell or blue-vitriol cells, and is maintained
undiminished until the material is exhausted.
The instrument which, as I have already said, I have
had in daily use for some five months, and which has many
days been jolted about in my carriage over rough city streets
July 18, 1885.]
CUETISS: IMMUNITY IN DISEASE.
67
for five or six hours at a time, has maintained its current
unimpaired in quantity or quality.
Another great need of the electro-therapeutist has been
some means of measuring the quantity of electricity — some-
thing that will answer to the balance of the apothecary. It
is quite usual to hear those using electricity speak of giving
the patient so many cells for such a contingency and so
many cells for another, which is just about as sensible as
it would be to advise a man to wear so many coats in the
Arctic zone and so many in the Antarctic, without specify-
ing the texture that shall make up each individual coat.
The sine and tangent galvanometers, which are used by
those employing electricity in the arts, are too cumbrous
and expensive for medical needs. Gaiffe, Bottcher, Stohrer,
Edelmann, and Hirschmann have each devised an absolute
galvanometer. Of these, the ones constructed by Gaiffe
and Hirschmann have been the best. Dr. De Watteville
enthusiastically indorses the former, while others allege that
it is faulty. Hirschmann's instrument has been well de-
scribed by Dr. B. Sachs.* I have had no experience with
it, but it appears to me to be complicated, and Dr. Sachs,
after a year's use of it, states that " it does not bear trans-
portation well, and the return of the needle to the zero
point is slightly impeded by the action of friction." It
seems, however, barring these disadvantages, to be a good
instrument. The cost seems to me to be the main drawback
to it. There has lately been constructed in this city an ab-
solute galvanometer which is superior, in my opinion, to any
other for the purposes of the electro-therapeutist. A cut is
Fig. 4.
herewith appended. The unit of measurement is the mini-
am pere — a unit which has lately come into use for medical
purposes. It was first suggested in 1878 by Dr. De Watte-
ville, and was adopted by the special committee of the In-
ternational Congress of Electricians. It represents the cur-
rent given by three Daniell's cells through the average
resistance of the human body, and medical currents range
in strength from one to fifty of these units.
The scale is graduated from one to fifty of these new
units. The working parts of the meter are inclosed in a
case about four inches square at the base and six inches
high, having a glass face, showing the pointer and scale.
The pointer is attached to the movable magnetic needle,
which is a steel disc suspended within a surrounding coil
* "Jour, of Nerv. and Mont. Dis.," vol. xii, No. 1, Jan., 1885.
of wire on two knife-edges, so as to oscillate freely in a
vertical plane. The movements of the magnet are indicated
by the pointer on the scale. The magnet is counterbalanced
and held in equilibrium, so that the pointer rests at zero, by
means of a small weight fixed to it below the center of
gravity. These are so arranged that the position of the
instrument relatively to the earth's magnetic poles is of no
account. The magnet, being so poised on frictionless knife-
edges, would be subject to prolonged and troublesome oscil-
lations ; but a dampening device is provided which consists
of a vane or fan of thin mica, extended upward from the
magnet in the back part of the case by means of a light,
rigid stem of aluminium. This vane moves broadside against
the confined air and brings the needle quickly to rest in
any position, without, in the smallest degree, interfering with
its sensitiveness. A locking arrangement also forms a part
of the instrument, by which the magnet may be lifted from
its bearings and fixed in an immovable position. By this
means the knife-edges and movable parts are protected
from damage during transportation and when not in use.
A leveling screw is placed on one side below, so that the
instrument may readily be adjusted to a proper position.
In use, the meter is placed in the circuit with the body
of the patient, so that all the current which flows through
the body flows also through the meter. In this situation
the pointer of the instrument gives a deflection which meas-
ures in absolute units the current actually passing and
doing work in the body.
The luxury of such an instrument can hardly be over-
estimated by any one making daily applications of elec-
tricity and desiring to work rapidly and precisely. For
example, a patient comes to you to-day, and you find that
you can employ twelve cells of your battery with no un-
pleasant effect. To-morrow he comes to you again, and, to
your surprise, you find that you need twenty-four cells to
obtain the same effect. The third day he comes still
again, and squirms with pain when you turn on more than
six cells. Your milliampere-meter solves the mystery. It
tells you that all the time your patient has borne about
ten or fifteen milliamperes of electricity, and that the daily
differences have been due to variations in the conductivity
of the skin, moisture in your sponges, heat of the moisture,
etc.
IMMUNITY IN DISEASE.
By ROMAINE J. CURTISS, M. D., Jouet, Iix.,
PROFESSOR OP HYGIENE IN THE COLLEGE OF PHYSICIANS AND SURGEONS,
CHICAGO.
(Concluded from page £2.)
One of the more important correlatives of the immunity
from disease given by natural selection is the history of (he
great epidemics of plague, black-death, typhus, etc. These
epidemics, during the dark ages, killed millions of people,
and were prevalent more or less continually. These dis-
eases were not conquered by sanitation. An epidemic now-
adays makes just as violent a warfare in Europe as epidem-
ics ever did, provided there is no acquired physical resistance
of tissue-cells to the poison of the germ. But the old epi-
demics lost their power and declined, and finally became
68
CUBTISS: IMMUNITY IN DISEASE.
[N. Y. Meu. Jolr.,
practically extinct. Efforts have been made to attribute
this extinction to sanitation. The London fire lias been
given the credit of conquering the sweating-sickness, and
the suppression of typhus and scurvy as epidemics has been
ascribed to the efforts of John Howard and Captain Cook ;
but if cleanliness, or alleged cleanliness, or prevention of
putrefaction, has cleaned out leprosy, black-death, jail-fever,
etc., why are not cholera, typhoid, diphtheria, scarlatina,
and other zymotics also subdued by the same alleged clean-
liness ? I think the only method of explaining the cessation
of the old epidemics is the method of natural selection.
When the epidemics prevailed, the germs, by combat with
tissue-cells, caused a variation in the cells. The persons
who acquired and maintained this variation transmitted it
to their children. In time there was built up a community
of people who had the power of resisting the germs of
these epidemics, and the epidemics died out.
I think we may apply this action of natural selection in
the community, as it is seen to subdue epidemics, to the
person, in order to explain the self-limitation of disease,
both limitation in duration of time and the limitation of
disease of different kinds to .corresponding organs or tis-
sues. Syphilis appears not to be limited to any definite
time, nor to any particular tissue or organ. Probably,
next to syphilis, tuberculosis meets with less resistance
among cells, and has less evidence of being self-limited in
time. There is evidence, however, that both of these dis-
eases are subject to the general law of limitation in both
time and successful antagonism from certain tissues. Syphi-
lis is certainly less violent than formerly. Modern authors
speak freely on this subject. This is not because treatment
has improved, for the treatment is the same now as when
syphilis was almost certain death. It is because the whole
of Christendom is syphilized, and natural selection is bring-
ing the races of men out of the bonds of this disease. The
various tissues of the body are acquiring a power of resist-
ance to the syphilis germ and its poison, and transmitting
this power of resistance by heredity. If one tissue after
another of the body acquires a resistance to the poison, it is
a sequitur that in time the tissue which is the last to acquire
the resistance will show the only signs and symptoms of the
disease. Syphilis will then be more limited in point of dif-
fusion throughout the body, and must necessarily be of
shorter duration. It will then present, in this respect, the
characters of those diseases which are limited to certain
tissues, and to a more definite period of time, notably
typhoid, scarlatina, measles, small-pox, etc.
But another feature of the question is that the develop-
ment of organisms is a resultant of actions and interactions
between them, so far as they are related to each other. When
the struggle for life is limited to a struggle between organ-
isms, the variation is not limited to one of the combatants
alone. Each gets a share of the variation. If the animal
attacked by a micro-organism acquires a variation giving
it greater resistance, it is likely that the attacking organism
by this means acquires greater virulence. The "survival"
in such a case bears direct relation to the organism which
has the greater resources. That the human species exists
to-day is proof enough that humanity at large is able to
survive in spite of the enemies which cause disease ; and
that the species survives by reason of natural selection
would appear to be clear enough. The defense appears to
be a variation of the cells in their power to resist a poison,
while the variation in the disease organism is an increase in
its virulence. The variation of the species of micro-organ-
isms by natural selection is a verified fact, and upon it
depend all the benefits derived from inoculation. If the
pathogenic organism of hydrophobia is bred in the bodies
of certain lower animals, it loses virulence. There can be
no method of accounting for this fact except that the tissue-
cells of the animal have less resistance than those of the
other animals which have given the organism its greater
virulence. The Bacillus anthracis is modified in the same
manner by artificial cultivation. On the other hand, reli-
able experimenters have determined that B. subtilis (hay
bacillus) can, by cultivation and inoculation, be changed to
B. anthracis. This variation of the species produces cor-
responding varieties in disease, and is the fact that underlies
the immunity to disease which is brought about by vaccina-
tion or inoculation. There are several methods of produc-
ing these varieties, such as cultivation, dilution, attenuation,
washing, etc. If natural selection can not explain these
various methods, I do not know what will or can. The
organism, varied from the type of its species in this way, as
a general thing, is unable to cause disease by entrance into
the body in the usual way, but depends upon accident.
The accident must include an injury to the tissues or celk
such as obtains in inoculation. When a wound is made
the cells are destroyed. Most organisms are proof against
septic bacteria unless there is a wound. Human beings have
outgrown, or rather out-developed, septic bacteria, unless
their invasion is preceded by an accident which causes a
wound. AYounded cells and tissues have lost their power
of physical resistance.
Another feature of inoculation is that the artificial
method of gaining a foothold inside the resistance of the
organism subject to disease, by means of inoculation, has
the effect of shortening the period of incubation. This is
true of inoculations of all varieties of pathogenic organisms.
It is, therefore, an inference and a verified truth that vac-
cination may prevent small-pox, even after exposure to the
latter. To deny the proposition is to deny that the period
of incubation is shorter in vaccination than in small-pox,
and the denial is also, by antithesis, an assertion that kine-
pox will not prevent small-pox.
Dr. Eccles's inference from his own data, as well as from
the facts here expressed, that the treatment of small-pox by
vaccination, or vaccination after exposure to small-pox, is
like treating strychnine poisoning by another dose of
strychnine, is one of the most stupendous instances of
logical' non sequitur to be found in medical literature. In
order to draw a like inference from different propositions,
the terms of the propositions must have some relations of
likeness. In Dr. Eccles's inference and statements there is
no shadow of likeness. He must first prove that the in-
cubation of small-pox from exposure is equal in time to
that of vaccination, and also that vaccination will not pre-
vent small-pox. If he had said that infecting the blood of
July 18, 1885.]
GURTISS: IMMUNITY IN DISEASE.
69
a small-pox patient with more small-pox poison was like
treating strychnine poisoning with more strychnine, the
terms of his proposition would have had more analogy-
Testimony shows that vaccination is good medical treat-
ment for small-pox, and, while the fact remains that kine-
ppx can prevent small-pox, the inference will be unavoidable
that the germs of each, in relation to the host and the dis-
ease, are antagonistic physiologically — as much so as atro-
pine and morphine. Their antagonism may depend upon
the priority of their invasion of tissues. Their difference is
the degree of .virulence of each, but in relation to the tissues
either is the antagonist of the other.
But Dr. Eccles's hypothesis, or absurdity, can be used
to good purpose. Suppose that on a future given day a
person is condemned to swallow a given poisonous dose of
strychnine, or arsenic, or morphine, and wishes to prepare
for it. In such a case the best method for the person will
be to accustom himself to the use of the poison. If Socrates
had known the relations of natural selection to the action of
poisons, he might have drank his hemlock with no less
grandeur and have saved his life. Dr. Eccles simply in-
verts the terms of natural selection in relation to poisons.
His proposition looks formidable and strange. It reminds
one of the man who tried to frighten a bull by standing on
his head with his feet in the air. The man's appearance
was unique, if not frightful, but was no protection against
penetrating horns, backed by the fury of the Durham.
I think the hypothesis that immunity from disease is
acquired by the interactions of tissue-cells and the patho-
genic organisms of disease is one that can explain all phe-
nomena of disease in this relation. Natural selection is one
of the verve causae in nature. To further establish this hy-
pothesis, it is, of course, necessary to examine other hy-
potheses to find if they will stand the test.
The hypothesis that a chemical compound is formed by
the micro-organisms, and left in the tissues, which prevents
their further action — as alcohol kills yeast, or acetic acid
kills Mycoderma aceti, and as the excremental products of all
.bacteria destroy the organisms which produce them — is cer-
tainly unable to explain anything. If it were true, nothing
could be easier to find in the tissues, and no such thing has '
been found. That destruction of certain tissues for which
the parasite has an affinity gives the immunity is destroyed
as an hypothesis for the reason that such tissues are repaired
by the recovery of. the patient, in all cases.
The oxygen theory ^of Dr. Salmon is too narrow a con-
ception for the occasion, and there are no verifications to
sustain it. Who can imagine that tubercle bacilli in the
lungs can consume the oxygen inhaled so rapidly that there
is not a sufficient supply for the lungs ? The inhalation of
oxygen is found to do harm in consumption as well as many
other diseases. If Dr. Salmon's hypothesis is true, the in-
halation of oxygen ought to not only cure, but prevent all
diseases of zymotic origin. Let us transfer the terms of Dr.
Salmon's proposition to another case. The terms are these
as quoted from Dr. Eccles's paper : " The poison of the
microbes intoxicates the cells. Retarded function [of the
cells] allows oxygen to increase in the circulation, thus
facilitating their gaining a foothold. Recovery is due to the
ability of the cells to resist the poison [this is true, and all
there is of it in relation to recovery and also to immunity],
use up their own oxygen, and so asphyxiate the microbes."
Dr. Salmon has not made an estimate relating to the venti-
lation of the human body with oxygen and the relative
amount consumed by microbes and cells, which is necessary
as a factor of this problem. It is quite likely that oxygen
cuts no figure in the problem except as a necessary ante-
cedent to all phenomena of life — microbic and human. I
will transfer the terms of this problem to another case like
it. Suppose a man and dog are confined in a well-ventilated
room, and the dog, being hungry, attempts to kill the man
to eat him. It is necessary to kill him first. The dog at-
tacks the man, and, getting him by the throat, chokes him.
Now the retarded function [of the man] allows the oxy-
gen in the room to accumulate or increase in the room, thus
allowing the dog to maintain his position. Now, if the
man recovers, it is due to his ability to overcome the dog's
hold on his throat, and then to use up his own oxygen, and
by so doing asphyxiate the dog — by using all the oxygen
himself. Dr. Salmon admits the solution of the question
by natural selection when he says the " recovery is due to
the ability of the cells to resist the poison." Immunity is
also due to the same fact. The oxygen theory is therefore
only a rider to the true solution ; very much such a rider,
too, as Mazeppa was, in so far as ability to guide the horse
is concerned. Dr. Salmon's theory assumes that the mi-
crobes are in the body by accident, and destroy the cells,
not to consume them, but in order to rob them of oxygen.
The position of the microbe is that of offense rather than
of defense.
It is evident that we can substitute nitrogen or bile in
place of the oxygen in this problem and do no violence to
the sense or the results. What prompts the dog in the
assault is the necessity for food. The same is true Avith the
microbes. The dog does not poison his prey, because he
kills it mechanically ; but this does not change matters any.
The man may have some knowledge of dog-combat, gained
from former experience, or may not ; but, if he saves his
life, it is not because he uses the oxygen in a well-ventilated
room himself at the expense of the dog, but because he
knows or learns a method of successful physical resistance
to the dog. If he learns a specific method of resistance to
the dog from actual combat, as punching the dog's eyes, or
choking him, in time, doubtless, he will tell his children the
method, and so transmit the gift by heredity to them, and
the dogs will all be obliged to take up with Mother Hub-
bard, who, by this time, should have a bone or two in her
cupboard.
The cell and microbe and man and dog present prob-
lems of warfare the terms of which are parallel and alike.
The combat in each case is due to that great biological law
which underlies all the sin of this world, which is that liv-
ing things are adapted to each other as a food-supply, and
the fittest will swallow the other. When Eve ate the apple,
the probable extent of the sin was in the consumption of
other living material. This would have been a guileless
world if all living things had been created to take their diet
from the inorganic world, and men "at meat" could sit
70
BOOK NOTICES.— CORRESPONDENCE.
[N. Y. Mbd. Joch.,
down to a table spread with samples from the inorganic
world — nitrogen, ammonia, carbonic acid, salines, and water,
instead of quail on toast, oysters, eggs, milk, lamb, chicken,
etc.
In both these cases of man and dog, cell and microbe,
we find corresponding and like general principles which
explain all such cases. These combats result in variation
of all organisms concerned. No case can be Vientioned
which can not be explained by this generalization. The
variation consists in an organic change with corresponding
functions in all organisms concerned. If the cells gain an
immunity from further attacks of microbes, it is because
variation, acquired by actual combat, has given them a
power of physico-vital resistance to poison, which they
maintain until the forces of atavism have taken this power
away. The phenomena of immunity, in point of duration,
correspond directly with the forces of variation and atavism.
That we are unable to know the character of the variation
and atavism which gives a cell the power to resist a poison,
or makes it susceptible to poison, proves nothing against
the hypothesis, but only proves that, for physical reasons,
the verification is difficult.
But, while on the subject of immunity from disease, it is
well to take a look at it from the standpoint of hygiene.
The study of physically acquired immunity from disease is
interesting oidy as a means or end of scientific accomplish-
ment, and is of no great practical value. The science which
can give a man immunity from disease only by subjecting
him to an actual combat for life with his personal enemies
is a science which is not worthy of being called hygienic.
Why not destroy the microbe before it attacks the man,
and gain the immunity by this means? Immunity gained
through actual disease reminds one of the subject who went
to his king and complained that his enemy had threatened
to kill him. The King said : " Don't worry, my man ; if
he kills you I will have him beheaded within an hour."
The man tried to appear comforted, but finally ventured to
suggest that the best preventive would be to behead the
enemy an hour before he made the threatened assault.
Immunity from disease, gained by costly combat with
poisonous microbes, is the method of nature without in-
telligence. The method is not worth imitation except pro-
visionally. The study of the microbe in this relation is
useful only as it will give the knowledge of the methods
which can compass its destruction while it is yet outside the
body and before disease is produced.
jtooh ftotites.
An Introduction to Pathology and Morbid Anatomy. By T.
Henry Green, M. L). Lond., etc. Fifth American from the
sixth revised and enlarged English edition. With one hun-
dred and fifty engravings. Philadelphia: Henry G. Lea's
Sun & Co., 1884. Pp. xx-17 to 481, inclusive.
An extended review of such a well-known book is unneces-
sary. We had already regarded the work as a model of its
kind, and the author's assurance that he believes the present
edition to be fully up to date will be received as sufficient proof
that nothing of importance has been omitted. The reader will
find several additions to the last edition. The introductory
chapter has been remodeled, a new chapter on tumors appears,
and the subjects of septicaemia and pyaemia are presented in an
unusually clear and compact form. For these improvements
the author expresses his obligations to his surgical colleague,
Mr. Stanley Boyd. The closing chapter, upon " The Vegetable
Parasites," appears beneath that gentleman's name, and is a
thorough and exhaustive resume of the subject. Appended to
this section is a brief description of the different methods of
cultivating and staining micro-organisms. In stating that the
book is up to the time, we need not add that the bacilli of
tuberculosis, cholera, and leprosy, and the micrococci found in
erysipelas, pneumonia, scarlatina, typhus, and gonorrhoea, all
receive due notice. The book has been most carefully revised,
and bears upon every page the marks of that care and accuracy
which have won for it an international reputation.
BOOKS AND PAMPHLETS RECEIVED.
A Text-Book of Medical Physics. For the Use of Students
and Practitioners of Medicine. By John G. Draper, M. D., LL.
D., Professor of Chemistry and Physics in the Medical Depart-
ment of the University of New York, etc. With Three Hun-
dred and Seventy - seven Illustrations. Philadelphia: Lea
Brothers & Co., 1885. Pp. 733.
A Manual of Human Physiology, including Histology and
Microscopical Anatomy ; with Special Reference to the Re-
quirements of Practical Medicine. By Dr. L. Landois, Profess-
or of Physiology and Director of the Physiological Institute,
University of Greifswald. Translated from the Fourth German
Edition, with Additions, by William Stirling, M. D., Sc. D.,
Regius Professor of the Institutes of Medicine, or Physiology,
in the University of Aberdeen. With 318 Illustrations. Vol.
II. Philadelphia: P. Blakiston, Son & Co., 1885. Pp. xvi-
515 to 1184, inclusive. [Price, $5.50.]
Berlin as a Medical Centre. A Guide for American Practi-
tioners and Students. By Horatio R. Bigelow, M. D., Member
of the American Medical Association, etc. [Reprinted from the
"New England Medical Monthly."]
On the Severe or so-called " Uncontrollable " Vomiting of
Pregnancy. By Graily Hewitt, M. D., F. R. C. P., etc. [Re-
printed from the " Transactions of the Obstetrical Society of
London."]
Report of the Board of Managers of the Pennsylvania Hos-
pital, 1885.
Corrfsponbenre.
LETTER FROM ST. LOUIS.
Railway Sanitation. — The Inspection of Meat. — The Closure of
Wells.
St. Louis, June 30, 1885.
Among the matters of importance to the public in regard
to general sanitation and of special interest to our profession
as custodians of the public health are the questions, What can
be done by our railroad companies, not only for the health of
their employees, but to secure that their buildings and rolling-
stock shall be kept in a thoroughly sanitary condition? and
then, What, are they doing?
For some time past the Missouri Pacific Railway System has
made provision for the efficient and skillful treatment of em-
July 18, 1885.]
CORRESPONDENCE.
71
ployees, who are injured or become sick in its service, by the
establishment and maintenance of a large hospital well situated
and with abundant room, and with the greatest facilities for
giving those who are entitled to it the very best care that is
possible.
Similar arrangements have been made by the Wabash Sys-
tem, although that organization has not established a large hos-
pital here. The surgeons of that company have formed a
medical society and hold regular meetings, at which papers are
read and discussed on such topics as are of special interest to
them.
Another step has just been taken by the Missouri Pacific
System. A circular has just been issued by Vice-President
Hoxie in which is expressed the desire of the managers to
place the property of the companies comprised in this system
in good sanitary condition, and attention is called at the same
time to the importance of such measures to the welfare and
prosperity of the employees. The managers express their in-
tention of hearty co-operation with all State and local boards
of health with which they may come in contact, and enjoin
similar hearty co-operation upon all concerned.
Dr. W. B. Outten, chief surgeon, is placed in charge of all
matters pertaining to the sanitary interests of the roads, and
all officers and employees are instructed to carry out any rules
and directions that may be issued by him. Sanitarians in the
East and West will await with interest the publication of Dr.
Outten's rules and directions, as the subject of railway sanita-
tion is almost a new one, and the chief surgeon of a system that
operates over six thousand miles of track through such a coun-
try as that in which these roads lie has an opportunity and a
responsibility such as fall to but few men.
Another matter of considerable local sanitary interest is
attracting more or less attention in the papers now. For some
years the citizens of all other leading cities of our country have
been more or less effectively protected from the dangers at-
tendant upon the use of diseased or tainted meats by systems of
meat inspection which, in so far as they were faithfully adminis-
tered, rendered it impracticable, or at least financially dangerous,
to offer spoiled meats for sale for human food. Strange as it
may seem, the city of St. Louis has had no such system of in-
spection, and, as a result, it has come to be the fact, as one of
the daily papers said, that " St. Louis is the great dumping-
ground for all the diseased and damaged meat raised in the
West." Last winter an ordinance was passed and an appro-
priation was made by which a very rigid inspection was estab-
lished and enforced to the great advantage of the citizens and
to that of honest dealers as well, but to the cost and extreme
discomfiture of those who had been wont to make money from
the poor by selling them diseased or tainted meats. The pro-
vision for this, however, was only limited, and when the time
came for making a new appropriation so that the same protec-
tion might be continued, to their shame be it said, a sufficient
number of the House of Delegates were found to cast their
votes against the appropriation to defeat it, and, consequently,
during the summer weather we are without the needed protec-
tion, and unscrupulous butchers and dealers know that our city
makes no provision for the protection of its citizens in this
regard .
Of course, this danger is one to which the poor are in a
peculiar degree exposed. The wealthier citizens purchase cost-
lier meats from dealers who can not afford to risk their reputa-
tion by selling bad meat, while the poorer classes buy from
those who have little or nothing at stake, and who too often
care for naught except to make what gain they may, even at
the peril of health or life to the unsuspecting victim. A bill
has now passed the Council, and will come before the House of
Delegates this week, which makes provision for the renewal of
efficient meat inspection.
A good deal of time has been taken up at the meetings of
the city Board of Health for some weeks past in considering
the subject of closing wells. An ordinance was approved March
25th last, to which I have referred in a former letter, which
made provision for the closing of wells that should be found on
examination to contain more than six grains of chlorine to the
gallon of water. The wells of the city are divided into two
classes, viz., those which are in the public streets or sidewalks,
and those on private premises. The first class, as a rule, are
situated at street corners, and have been sunk by the owners or
lessees of saloons or groceries where beer and liquors are sold,
for the purpose of attracting custom from teamsters and others
who, while securing a free drink for their horses, will step in-
side and spend five or ten cents for a drink of what may be a
little more dangerous in its effects than the polluted water of
the wells. Many of these wells were resorted to by neighbor-
ing families because the water was clear and cool.
By the ordinance referred to, all wells located in the public
streets which ^should be found to contain six or more grains of
chlorine to the gallon were abolished, and, on a certificate to
that effect from the Board of Health, it was made the duty of
the Street Commissioner to cause them to be filled at the public
expense. At a meeting of the Disbursing Committee of the
Sanitary Aid Association this week it was reported that, of one
hundred and sixty-one wells on public streets which had been
condemned, one hundred and fifty-two had been filled. There
was a good deal of opposition to the enforcement of this sec-
tion of the ordinance on the part of the saloon-men, who felt
that the closing of their pumps would seriously interfere with
their business. Besides, it was argued that it would cause much
suffering to animals. One man was very anxious to be allowed
to retain his well, with the stipulation that the handle should
be removed from the pump and be kept within the saloon, and
only be taken out to pump water for horses and stock ; in no
case to pump water for cooking or drinking by human beings.
The Board of Health could see no way to insure its really
being used only for cattle, and declined to make any such modi-
fication of the order. A case was made and carried to the Su-
preme Court, which last week rendered a decision sustaining
the ordinance and the action of the Board of Health in enforc-
ing it.
The action in regard to the wells on private property is by no
means so simple as that in regard to those on the public streets.
There are several complications which do not arise in dealing
with the water question in Eastern cities. I shall speak of these
directly. The ordinance declares all wells located on lots of land
fronting on streets, avenues, or alleys, in which the public water-
pipe is laid, to be nuisances, except those tchich are used exclu-
sively for manufacturing or stable purposes or for watering stock,
or which may be proved, to the satisfaction of the Board of
Health, to contain pure water. [Italics mine.] "Any water in
wells which shall contain six grains or more of chlorine to a
gallon of water shall be deemed to be impure."
One of the first cases which came up before the Board of
Health under the section relating to wells on private property
was that of a woman who used the water for washing and
rinsing clothes. The question at once arose whether such a well
was to be excepted from condemnation under the plea that this
was to be considered as using the water for manufacturing pur-
poses.
After some discussion, inasmuch as the board were informed
that a case had been made up so as to secure a ruling of the
Supreme Court as to the whole scope of the law, it was re-
solved to hear the statements of the various well-owners as to
CO RRESPONDENCE.
[N. Y. Med. Jodr.,
the" use made of the water, and to delay making any final
order until the decision of the Supreme Court should be ren-
dered. It seems now that a good deal of time has been lost, as
the case that was carried up and the decision of the Court con-
sider only the wells in public streets.
Of course, in dealing with these cases, the Board of Health
has encountered the usual prejudice against innovation which
is always met with. There has been the usual number of old
residents who " have drunk the water from that well for thirty
years, and there has never been a case of sickness in the house
the whole time." There have been parents whose sick children
have been refreshed when fevered by the cool water from that
well, and have got well, and who, therefore, can not be con-
vinced that the water is unwholesome for well people.
There have been people who have lived in the same locality,
and have drunk water from the same well during two cholera
seasons, and who therefore refuse to take alarm at the statement
that the water contains from twelve to twenty grains of chlo-
rine to the gallon. All these cases are only repetitions of the
experiences which occur wherever well-filling is taken up as a
sanitary precaution."
But two difficulties exist here which, I think, are somewhat
peculiar. First, as everybody knows who has ever visited St.
Louis, our water is by no means clear. At its best it holds in
suspension a sufficient quantity of fine impalpable matter, of a
sort of yellow-ochre color, which characterizes the water of the
Missouri Kiver, from the point where the Yellowstone River
empties into it, to give it the appearance of lemonade; at other
times it contains enough earth to give it the color of cafe au
lait. On allowing it to stand for some hours, all, or nearly all,
of this solid matter will settle, and clear water can be obtained
for washing and rinsing clothes. (For drinking purposes most
people prefer it "in its rich natural state.") As a matter of
fact, however, most of those who take in washing, and are de-
pendent upon their laundry-work for their livelihood; have no
facilities for settling the river water, though a good many of
them have wells from which they have drawn water for rins-
ing. It certainly would be a hardship to deprive such people
of the opportunity so to use the water, and yet in nine cases
out of ten where they use the water for this they will also
use it for drinking, as it is so much cooler than the hydrant
water.
Another difficulty that has been encountered is the fact that,
especially in German neighborhoods, there is a prevalent opinion
that salting a well will purify the water and make it whole-
some, as well as keep it free from various bugs. Therefore, in
a good many cases, it has proved that wells which contained a
very large amount of chlorine, and, consequently, were supposed
to be badly polluted by sewage, really owed the chlorine to salt
that had been thrown in by the owners for the purpose of pre-
serving the water from contamination.
LETTER FROM WASHINGTON.
The District Medical Society.— The City's Water-Supply .— The
International Medical Congress.— The Hospitals.— Political
Appointments.
Washington, July 12., 1885.
There has been very little of general interest here since the
adjournment of Congress, so far as medical matters are con-
cerned.
The District Medical Society adjourned for the summer last
Wednesday. The meetings have been well attended through the
year, and interest has been maintained far into the hot term by
the discussions on Asiatic cholera and the water-supply of the
city. The water-supply question is not yet settled, and there
has seemed to be a disposition to make it rather a political than
a scientific matter, owing to the apparent criticism of the authori-
ties involved in the discussion. Some [joints were settled : First,
that there was a waste from the canal into the source of the
conduit at the river, and, second, that the drainage-basin into the
reservoir had included farmers' outhouses, privies, and pig-pen
refuse. All this has been corrected, and there is now a senti-
ment of relief. As usual, those responsible for. this not very
cheerful state of affairs at first denied the existence of the evils
as alleged, and later on abused those engaged in the discussion
of them. The water-supply is still inadequate, and a new con-
duit and an additional reservoir are being constructed. This
will furnish an abundance of water for a great many years to
come. It is stated that a sewer-pipe from the hospital on the
Soldiers' Home reservation passes directly under the new reser-
voir, and much apprehension is felt by those who know how
easy it is for a sewer-pipe to become loose at its connections
from the escape of gases and fluid through the cement. This
prospective evil admits of a practical remedy by changing the
direction of the sewer.
Before adjournment the society re-elected its former officers,
Dr. W. W. Johnston, president, and Dr. Thomas McArdle, sec-
retary. Those gentlemen who were originally appointed on the
International Medical Congress, and retained by the new com-
mittee, have resigned. There was no local grievance.
Dr. J. F. Hartigan, of this city, now in London, is expected
to return on the Germanic, which will sail about the 27th of
August. The doctor has been hard at work, and has an appoint-
ment every day at the Soho Square Hospital and at the East
London Children's Hospital.
The rage for incrimination and investigation reached Wash-
ington some time since, but seems to have about expended itself.
The Children's Hospital imbroglio, that at the Columbia Hospi-
tal, and the Wales Court-Martial are the principal topics of
medical gossip. In the former case one gentleman, long con-
nected with the hospital, has resigned ; at the Columbia Hospi-
tal, Dr. Murphy, the physician in charge, has been exonerated.
Dr. R. S. L. Walsh has resigned from the consulting board
of the Providence Hospital, and has accepted a position as one
of the attending physicians to the Garfield Hospital.
The scramble that took place between the hospitals last year
for the appropriation of fifteen thousand dollars, set apart by
Congress for hospital purposes, has been happily avoided this
year by the appropriation of a specific sum for each.
Dr. T. I. Chew has been appointed physician to the alms-
house hospital, vice Dr. T. P. C. Hazen, resigned.
With the coming in of the new administration a race began
for the position of health officer of the district, now held by Dr.
Smith Townshend. As the present commissioners were decid-
edly friendly to Dr. Townshend, and as he has had the support
of his brother, a member of Congress from Illinois, the various
applicants have not up to this time received much encourage-
ment. With the forthcoming change in commissioners it is
said a change will be made.
The Board of Pension Examiners has been reorganized to
correspond to the views of the politicians by removing Dr. Rob-
ert Reyburn. The dissatisfaction at the new arrangement has
been so great that two boards have been formed. It is sincerely
to be hoped that America may be enlightened and patriotic
enough some day to allow honest and efficient medical officers
to remain without reference to changes of the administration.
If the incumbent is unfitted or unworthy, that would be abun-
dant reason for making a change. Such a reason would not be a
political one, but the spoils system, with its outrageous abuses,
seems now, as in the past, to be the most tenderly cherished
tenet of political faith.
July 18, 1885.]
LEADING ARTICLES.
73
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Poster, M. D.
NEW YORK, SATURDAY, JULY 18, 1885.
THE INTERNATIONAL MEDICAL CONGRESS.
It was with expressions of anything but hopefulness that we
wrote last week of the prospects of the Congress, and we were
particularly emphatic in the view that we had insisted upon
from the outset, that the entire responsibility for the threatened
disaster rested upon the American Medical Association, and not
upon its new committee. For a time it seemed as if we were
almost alone in the advocacy of this view, but since our last
issue was published several things have happened which we
interpret as going to show that the responsibility of the Ameri-
can Medical Association is getting to be more and more recog-
nized.
The comments of some of our contemporaries are indicative
that they at least are beginning to recognize it, and it is spe-
cially noteworthy that the " Medical Bulletin," edited by Dr.
Shoemaker, takes considerable pains to show that the commit-
tee acted under such instructions that it could not do otherwise
than as it did. A most telling piece of testimony in the same
direction comes to us in the shape of a letter from Dr. Howard,
of Baltimore, which we publish elsewhere in this issue. Ex-
plaining why he declined to sign the Baltimore resolution, Dr.
Howard puts himself squarely in accord with its signers on the
real issue, and explicitly states that he concurs with the Boston
resolution, which expressly fixes the responsibility upon the
association. It is quite possible that there are others who
are perfectly willing to express themselves to this effect, but
hesitate to attach their names to anything which may seem
like a reflection upon the members of the committee as indi-
viduals.
If the association can be made to feel that its action in
this matter meets with very general condemnation, there is
some hope of its being rescinded in St. Louis next year. If the
status quo should then be restored, there would still be more
than a year in which to prepare for the Congress, and the gen-
tlemen whose further services in its organization have been
lost for the time being, in consequence of their haviDg resigned
from the committee in disgust, might perhaps be induced to
reconsider their determination. It seems now, therefore, that
a break may be made in the impenetrable hopelessness of a
week ago. But the only way to bring the American Medical
Association to its senses is for those of the committee's nomi-
nees who have the success of the Congress more at heart than
their own tenure of office to continue the good work which has
been begun in Philadelphia, Boston, Baltimore, and Washing-
ton. These cities happen to be situated in the East, but it is
assuredly by no sectional feeling that they have been led, and
we think our friends in other quarters of the country make a
great mistake if they so interpret the action taken. It has un-
questionably become the duty of every well-wisher of the Con-
gress, no matter where he may live, to decline any participation
in the emasculated affair which its present organization must
necessarily lead to. The impression thus made upon the Ameri-
can Medical Association, together with the unusual care which
we hope to see taken in the choice of delegates to its next
meeting, may result in the regeneration of that body. This is
a matter of even greater importance than the success of the
International Medical Congress.
BROOKLYN AND THE INTERNATIONAL MEDICAL CONGRESS.
We have heretofore given the new committee on the Inter-
national Medical Congress the credit of having done as good
work as seemed to be possible under the stringent restrictions
imposed upon it by the New Orleans meeting. Our attention
has lately been called to the fact of the very few appointments
that fell to the city of Brooklyn — only three in number, while
Philadelphia has forty-seven, Boston thirty, Baltimore twenty,
and Washington (exclusive of army and navy surgeons) four-
teen. In view of the stress that the New Orleans meeting laid
on the principle of geographical representation, and bearing in
mind that Brooklyn has a population of nearly three quarters
of a million — larger, therefore, than that of either of the other
cities mentioned, except Philadelphia — it is difficult to avoid the
thought that the committee lost sight of the geographical prin-
ciple in this particular instance. The principle is one which
we consider it absurd to proceed upon in such a matter, and
we should favor the best possible list of officers, even if every
one ofthem lived in an obscure village ; but, if it was to be car-
ried out, it should have been done equably. Especially should
such a glaring exception not have been made with regard to a
city where so much is done to advance medicine as in Brook-
lyn. To be sure, the three appointees from that city, Dr.
Hutchison, Dr. Squibb, and Dr. Raymond, are quite capable
of making an excellent showing for Brooklyn, in case they at-
tend the Congress, but they might appropriately have been re-
enforced by such men as Armor, Bell, Butler, Byrne, Fowler,
French, Gray, Hutchins, Jewett, Mathewson, Pilcher, Rock-
well, Segur, Sherwell, Skene, Speir, Thayer, Westbrook, and
Wight — men whose names are known wherever current medi-
cal literature is read, and who are recognized leaders in the
several branches of medicine to which they have devoted them-
selves.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Health Department for the following
statement of cases and deaths reported during the two weeks
ending July 14, 1885 :
DISEASES.
Week ending July 7.
Week ending Jul; 14.
Cases.
Deaths.
Cases.
Deaths.
0
0
1
• 0
Typhoid fever
13
4
9
31
2
35
5
9
4
4
4
3
66
12
55
10
41
21
55
24
3
0
2
1
74
MINOR PARAGRAPHS.
[N. Y. Med. Jodh..
Small-pox. — A ship which arrived at this port last week
from Liverpool had lost two of her crew with small-pox during
the voyage. The vessel was quarantined and fumigated. Press
dispatches allude to an epidemic near Creston in Iowa. It is
stated that during the three weeks ending on Monday, the 13th
inst., thirty-two deaths occurred from the disease in Montreal,
fifteen of which took place during the last week of the three,
and that six new cases were reported on the 13th. As will be
seen by the report of infectious diseases, five cases were discov-
ered in New York during the fortnight ending on Tuesday, one
of which proved fatal.
New York State Medical Association, Fifth District
Branch. — The first annual meeting of the Fifth District Branch
will be held in Brooklyn, on Tuesday, October 13, 1885. There
will be a morning and afternoon session. All fellows desiring
to contribute to the meeting, either by reading papers, notes, or
communications, or by exbibiting specimens, are respectfully
invited to notify the secretary to that effect at their earliest
convenience.
J. C. Hutchison, M. D., President.
E. H. Squibb, M. D., Secretary, 30 Doughty Street, Brooklyn.
The International Medical Congress and the Medical
Profession of Washington.— At a meeting of medical gentle-
men held in Washington, D. C, July 11, 1885, the following
preamble and resolution were adopted :
Whereas, Certain changes have been made in the constitu-
tion and organization of the Ninth International Medical Con-
gress which seem to us unwise, injurious, calculated to bring
the profession into disrepute, and to endanger the success of the
Congress, therefore
Resolved, That we, the undersigned, decline to hold any
position under the said Congress as now organized.
Joseph Taber Johnson, M. D. S. C. Busey, M. D.
W. W. Johnston, M. D. H. C. Yarrow, M. D.
Swan M. Burnett, M. D. A. F. A. King, M. D.
B. F. Pope, M. D., U. S. Army. Frank Baker, M. D.
E. Carroll Morgan, M. I). D. Webster Prentiss, M. D.
J. Ford Thompson, M. D. S. O. Richey, M. D.
D. L. Huntington, M. D., U. S. Army.
The International Medical Congress and the Council of
the New York State Medical Association.— The following
resolution, recently adopted, reached us too late for insertion in
last week's issue :
Resolved, That the Council of the New YTork State Medical
Association respectfully recommend to the Committee of Ar-
rangements for the International Medical Congress the following
modification of the rule by which the American membership of
the Congress is to be constituted, to wit : That the American
membership of the Congress be constituted of delegates who shall
be entitled to participate in the business and scientific proceedings,
and of members who shall be entitled to participate only in the
scientific proceedings of the Congress ; that the delegates may
be appointed by the American Medical Association and by State
and local organizations in affiliation therewith in the propor-
tion of one delegate for every ten or fraction of ten members of
the organizations thus represented ; that members of the regu-
lar medical profession of the United States may become mem-
bers of the Congress by registering their names as such and by
taking out tickets of admission.
The University of Vermont. — It gives us pleasure to insert
the following deserved tribute to Dr. Wright:
" The Medical Faculty of the University of Vermont, having
been unable to retain permanently the services of Professor J.
W. Wright, of New York, as professor of clinical surgery, beg
leave, in accepting his declination of the position, to extend to
him, both personally and officially, their grateful appreciation
of the eminent service he has already rendered the University
of Vermont by his course of Lectures on Surgery, just con-
cluded.
" As a skillful operator and a scholarly lecturer, both didactic
and clinical, Professor Wright has ^iven universal satisfaction.
In leaving the Medical Department of the University of Ver-
mont, Dr. Wright carries with him the best wishes of the Medi-
cal Faculty and of the corporate authorities of the Univer-
sity."
M. II. Buckham, President, University of Vermont.
A. F. A. King,
A. P. Grinnell,
[Signed.] R. A. Witthaus, {> Medical Faculty.
J. Henry Jackson,
Henry D. Holton,
A New Hospital, endowed by the late Mr. Robert A.
Packer and named after him, was opened at Sayre, Pa., on
Monday of this week. The building was formerly Mr. Packer's
residence.
The late M. Gueneau de Mussy.— According to the " Union
medicale," a subscription has been started to obtain funds for
a bust of the late M. Noel Gueneau de Mussy, to be placed in
the Hotel-Dieu.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from July It, 1885, to July 11, 1885 :
Havard, Valery, Captain and Assistant Surgeon. Assigned to
duty at Fort Wadsworth, New Y'ork Harbor. S. 0. 140,
Department of the East, July 2, 1885.
Wyetii, M. C, First Lieutenant and Assistant Surgeon. As-
signed to duty at Fort Wayne, Michigan. S. O. 140, Depart-
ment of the East, July 2, 1885.
Powell, Junius L., Captain and Assistant Surgeon. Ordered
from Department of the East to Department of the Missouri.
S. 0. 155, A. G. 0., July 9, 1885.
Birmingham, Henry P., First Lieutenant and Assistant Surgeon.
Ordered from Department of the Missouri to Department of
the East. S. O. 155, A. G. O., July 9, 1885.
Naval Intelligence. — Official List of Changes in the Medi-
cal Corps of the United States Navy during the week ending
July 11, 1885.
Byrnes, J. C, Passed Assistant Surgeon. Detached from the
Powhatau for duty at Navy-Y'ard, Norfolk, Va.
Cordeiro, F. J. B., Assistant Surgeon. To the Powhatan as re-
lief of Passed Assistant Surgeon Byrnes.
Curtis, L. W., Assistant Surgeon. To Philadelphia for exami-
nation preliminary to promotion.
Drennan, M. C, Surgeon. Placed on waiting orders.
Fitzsimmons, P., Surgeon. Duty on Receiving Ship Franklin,
Norfolk Navy-YTard, continued until July 1, 1886.
Society Meetings for the Coming Week :
Monday, July 20th: Chicago Medical Society; Hartford, Conn.,
City Medical Association.
Tuesday, July 21st: New York Academy of Medicine (Section
in Theory and Practice of Medicine) ; Medical Societies of the
Counties of Kings and Otsego (Cooperstown), N. Y*. ; Og-
densburg, N. YT., Medical Association.
Thursday, July 23d : New YTork Academy of Medicine (Sec-
tion in Obstetrics and Diseases of Women and Children) ;
New York Orthopaedic Society.
July 18, 1885.]
LETTERS TO THE EDITOR. — PR 0 GEE DIN OS OF SOCIETIES.
75
fetters to tlje <£oitor.
THE RESPONSIBILITY FOR THE INTERNATIONAL MEDICAL
CONGRESS MUDDLE.
Baltimore, July 13, 1885.
To the Editor of the New York Medical Journal:
Sri?: I ask leave to say that I declined signing the resolutions
in regard to the International Medical Congress that were for-
warded from this city, and published in your journal of the 11th
nst. (page 45), because they place the blame for the lamentable
state of affairs entirely on the action of the new committee at
Chicago, while, as it seems to me, that committee acted simply
in accordance with the stringent restrictions imposed upon it
by the unwise and revolutionary conduct of the American Medi-
cal Association at New Orleans in nullifying the action of the
first committee, and thus opening the Pandora's box of the
countless evils now agitating the American medical profession.
The resolutions passed at the meeting of the medical men of
Boston, and published on the same page of your journal, meet
with my cordial concurrence.
With great respect,
W. T. Howard.
|)roceebtncrs of Societies.
NEW YORK ACADEMY OF MEDICINE.
Meeting of June 4, 1885.
The President, Dr. A. Jacobi, in the Chair.
Contagious Ophthalmia in some of the Orphan Asylums
and Residential Schools of New York City. — Dr. Richard
H. Derby, the author of the paper, said it appealed to the
hearer on the threefold ground of philanthropy, medicine, and
social science. He referred to the report made to the County
Medical Society in 1884 concerning the condition of the eyes
of the inmates of three institutions in this city, and stated that
since then twenty-four other institutions had been visited, con-
taining in all 7,440 inmates. After describing the appearances
of the eyes of one suffering from contagious ophthalmia, Dr.
Derby said that in the first institution visited 24'5 per cent, of
all the inmates had contagious conjunctivitis; in the second,
488 out of 1,586; in the third, 111 out of 782 ; in the fourth,
93 out of 188. The number of cases in this institution had de-
creased since his first visit, after which each of the inmates had
been given his own towel and brush, etc., and the general
hygienic state had been improved. The proportion of cases in
several other institutions was then mentioned.
It was not the object of the paper to consider in detail the
various conditions which led to the development of contagious
eye diseases in the asylums visited. The part played by imper-
fect quarantine, bad lavatories, overcrowding, bad hygiene— all
these had been discussed elsewhere. His purpose would have
been attained if he drew attention to the fact that in the
asylums of our cities, where children in large numbers were
housed, being taken from unhealthy homes, there existed to an
alarming extent a disease fraught with danger to the eyes of all
assembled there. It would be noticed that in the institutions
visited the larger number of cases of contagious ophthalmia
existed where the inmates used the towels indiscriminately,
washed in the same basin or trough, and slept together, and
also where there was general bad hygiene. The disease might
be present without attracting the attention of the attendants.
In too many instances it went on insidiously, undermining the
health of the eyes, until finally an acute attack took place, and
gave rise to an epidemic of contagious ophthalmia. We had
just seen that of the 7,440 inmates of institutions visited, 1,428,
or 1919 per cent., had contagious conjunctivitis, or nearly one
in every five. Besides, in several of the institutions it was the
custom to send the worst patients to their homes, where they
might seek treatment outside, thus rendering probable the fur-
ther spread of the disease among the neighbors. The parents
of such children were not properly situated for carrying out
effectual treatment, and were unable to care for them in a suit-
able manner. In many cases it was to the advantage of the
institution to receive as many inmates as possible, and thus
overcrowding was encouraged.
The Board of Health should be notified of every case of con-
tagious ophthalmia in any of the institutions, and accommoda-
tions should be provided for isolating the patient until he was
no longer capable of communicating the disease. There were
enough cases of contagious ophthalmia in the institutions at
present to fill a hospital devoted to their isolation and treat-
ment. It behooved the members of the Academy of Medicine
to make emphatic protest against the continuance of the present
state of things.
Dr. H. Knapp said the statements of the speaker ought in
no way be underrated. He had been connected with a number
of institutions as ophthalmic surgeon, and knew that in a num-
ber of them, and perhaps at certain periods in all of them, con-
tagions ophthalmia existed. Sometimes the spread of the dis-
ease had been so great that the authorities of the institutions
were forced to close them and to farm the inmates out. But
he could, on the other hand, state that in many of the institu-
tions the greatest care was taken to stamp out the disease. He
mentioned the Catholic Protectory in particular, where, when
an epidemic broke out, they called physicians and sought in
every way possible to stamp out the disease, and the spread of
the blennorrhoea was largely controlled. But, where an institu-
tion was once invaded, a number of cases were liable to continue
for a long time. Two institutions never admitted a patient
with eye disease until they had received a certificate from him
that the disease was not contagious; the patients were sent to
an ophthalmic institution until they were cured of the conta-
gious affection. These institutions were remarkably free from
eye diseases. He thought the suggestion of the author of the
paper regarding competent inspection of all cases of eye dis-
ease in these institutions a good one, and believed that, if a
physician were engaged to make a monthly report of the con-
dition of the eyes of the inmates, at least large epidemics would
be avoided. In this seemed to be the nucleus of the paper, and
he knew of nothing more philanthropic which could engage
attention.
Dr. D. B. St. John Roosa said that that afternoon, at the
request of the physician of an asylum, he had examined the
eyes of 242 inmates and found 67 cases of conjunctivitis. These
children were under as good care as they could have, thanks to
the labors of the author of the paper, except that there was not
isolation. But the authorities of the institutions were not alto-
gether to be blamed for the existing condition of things. If
there was any power in the Board of Health to correct such
matters, it was its urgent duty to do so. Children suffering
from eye disease were often forced upon the managers of asy-
lums in a manner that they could scarcely resist. The writer
had observed with great propriety how very wrong it was to
send these children back to their already overworked parents or
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jocr.,
guardians with the hope that they might remedy the matter.
The remedy was easy. The tax-payers should pay for a hospital
where patients suffering from contagious ophthalmia could he
sent and retained until cured and then he returned to the insti-
tution without danger of spreading the disease. The suhject
■was one deserving the consideration of political philanthropists,
and the Board of Health should insist upon the erection of a
suitable hospital, and it would be found, as it had always been
found in like cases, that the people of New York were ready to
give their money for deserving charities.
Dr. Oakman, of Nyack, said that during the winter the au-
thorities of the institution at that place, where about one hun-
dred inmates were admitted, failed to isolate certain cases of
eye trouble which he advised should be done, they maintaining
that the disease was- the result of cold. In order to keep the
inmates warm they were huddled together in an ill-ventilated
room, and the result was that in the spring there were forty-
four cases of catarrhal trouble of the eyes, seven of acute granu-
lar trachoma, and one of purulent ophthalmia.
Dr. C. R. Agxew said his interest in this matter had begun
nearly thirty years before, when he saw a great many cases of
contagious conjunctivitis during a famine in Ireland, and to this
day that disease was quite common there, having started from
overcrowding in poor-houses and other public institutions. He
referred to a school in this city where contagious ophthalmia
was communicated to eight tenths of the inmates, probably
largely by the habit of washing together in one trough. They
were also insufficiently fed, and several slept in the same bed.
A remarkable change for the better had taken place when they
were placed in tents and given four hundred quarts of milk a
day instead of fifteen quarts. Dr. Agnew had great faith in
the effect of agitation in bringing about a reform of abuses. It
was not always wise to seek legislation, but in this case he
thought something should be done by way of legislation. It
should be required of those who were about to found an insti-
tution to lodge a certificate showing that they had made proper
provision for air-space, shelter, food, and medical attendance for
a certain number of inmates, and it should he made impossible
for such institutions to receive more persons than the number
for which they had the lawful accommodations. This was quite
as possible as to regulate the number of passengers which a ship
of given measurements should carry. The large majority of
children in these institutions having chronic conjunctivitis never
recovered, and they went to make up that large body of drift-
ing, despairing creatures who infested our towns and cities.
Mr. Gerry, of the Society for the Prevention of Cruelty to
Children, explained the manner in which commitments were
made to these institutions, and said that, with certain excep-
tions, many of the institutions where the children were sent
were entirely under the control of persons who had no knowl-
edge of medicine, or even of nursing, and there was no provi-
sion in the law which required them even to seek the advice of a
physician. Unless they were required to submit to the judg-
ment either of a medical board or of some competent medical
man, they would always have in their institutions cases of con-
tagious ophthalmia. He was entirely in accord with the views
expressed by Dr. Agnew, and thought that something should be
done by law to provide for an oversight of these institutions by
medical authorities. He thought, so far as an ophthalmic hos-
pital was concerned, that the remedy was simple. Let the
State pay liberally for the care of such cases, and they would
find proper isolation and treatment. The difficulty with regard
to the Board of Health was that it was a quasi-politieal body;
it already had its hands too full of work, it had not the means,
and, when money was asked for, it was put off with the reply
that it was always calling for money. One objection to an
ophthalmic hospital was that the people would feel that as soon
as a child was sent there its condition was hopeless.
Mr. Milhau, of the State Board of Charities, explained the
duties of that board with regard to recommending the estab-
lishment of institutions organized by private individuals, and
said that, while such institutions usually started under favora-
ble conditions, it was only a short time before they began to
receive children faster than they were able to provide accom-
modations for them. Then there were institutions which were
considered absolutely safe, being under the highest medical su-
pervision, and yet ophthalmia would hreak out.
The President said it was apparent, from the remarks which
had been made, that it was almost impossible to keep contagious
ophthalmia out of institutions. The same was true of every
other contagious disease ; they all made their appearance at
times in institutions crowded with inmates. All of these insti-
tutions were meant to do good, and all did at the same time a
great deal of harm. Where there were many children there
were many opportunities for danger. Measles usually was a
very mild disease, but when it broke out in public institutions
it became very dangerous, and the same was true of all conta-
gious diseases ; they were more fatal when present among the in-
mates of crowded institutions. In an eve hospital a mild case
of ophthalmia would become a very severe one, and he was not
sure that much good would come from a hospital devoted spe-
cially to those cases. The question would finally arise, whether
public institutions where large numbers of persons were con-
gregated should be allowed to exist at all. If the children
gathered in those which at present existed were farmed out it
would be much better for them ; there would be fewer cases of
ophthalmia and of blindness.
Dr. W. F. Mittexdorf said it was difficult to make the pub-
lic understand two points with regard to contagious ophthal-
mia: first, its great danger to the eyes, and, second, the length
of time it required to cure it. He had had much to do with
asylums, and he thought, with the president, that the crowding
of children together in institutions was a great source of dan-
ger. In certain institutions where the inmates lived in cottages
he had seen little of eye disease. Another point which was too
often overlooked was the extreme contagiousness of the affec-
tion. It was because of its great liability to spread that the
eye institutions in the city did not like to accept cases of con-
tagious ophthalmia. The suggestion of the president was, it
seemed to him, the best that c ould be adopted — namely, to put
as few inmates into one building as possible.
Dr. Agxew offered the following resolutions, which were
unanimously adopted :
Resolved, That it is necessary and expedient that steps be
taken to prevent the occurrence of communicable eye diseases
in the schools and asylums of New York and vicinity.
Resolved, That the Council of the Academy be requested to
take the matter of the paper into its immediate consideration,
to obtain the co-operation of the writer of the paper, of the
Society for the Prevention of Cruelty to Children, of the State
Board of Charities, of the State Charities Aid Association, and
others interested in the subject, for the purpose of lessening the
prevalence of communicable eye disease.
Dr. Roosa wished to say one word more in favor of an
ophthalmic hospital. It had been shown in the discussion that
contagious ophthalmia, although easily spread, was also amena-
ble to treatment, and, so long as institutions existed where it
was liable to occur, there should be a hospital where patients
could he sent for isolation and treatment. Of course, this would
not be necessary when things were in New York as they were
in Utopia, and children were all farmed out instead of being
put into institutions.
July 18, 1885.]
PRO CEED TNOS OF SOCIETIES.
77
OBSTETRICAL SOCIETY OF PHILADELPHIA.
Meeting of June 1885.
( Concluded from page 55.)
The Surgical Treatment of Infants.— Dr. Willard's paper
was concluded as follows :
Congenital hydrocele rarely requires much surgical inter-
ference beyond an evaporating lotion of chloride of ammonium
or alcohol, as a few weeks will often close the canal, if hernia
does not co-exist — a fact which can be determined by non-trans-
lucency and capability of reduction. Should the connection
with the peritonaeum fail to close, puncture, with the applica-
tion of a truss, will usually complete the cure. A hydrocele
with closed canal is better treated by tapping and injection than
by seton. The diagnosis between encysted hydrocele of the
cord, hernia, and undescended testicle is sometimes difficult, but,
if the surgeon remembers that the former is simply a cyst in
some unobliterated portion of the peritoneal coat of the cord,
that its rounded shape can be detected if it is pulled well down
into the scrotum, that it is usually translucent, that the impulse
is not so decided as in the case of hernia, that it returns to the
abdomen only by being pressed upward and not with a slip and
gurgle, he will rarely be led astray. A hernia may co-exist
with either of the above-mentioned conditions, but, if non-
adherent, careful isolation will settle the diagnosis. Should the
hernia become strangulated or the non-descended testicle be-
come inflamed and infiltrated, the most careful examination will
be necessary. In retained testicle, its absence from the scrotum
will be the first point in arriving at a decision, but even in such
a condition the organ might be within the abdomen and an en-
cysted hydrocele present, or the testis might, as has recently
fallen under my notice, slip into the tissues of the perinasum
and be exceedingly difficult to discover. In the case just men-
tioned it sometimes requires numerous manipulations to cause
the missing organ to return to its place in the pouch. Should
hernia and retained testicle both exist, a double purpose can be
gained by drawing the latter down, and pushing the former up
and then applying a truss. The successful retention of the
organ within the scrotum is a matter of great difficulty, and
removal is scarcely justifiable in young persons unless pain or
inflammation ensues. Extirpation, if required in later youth,
will probably not interfere with the procreative power of the
individual, since one gland will supply all requisite material,
and the affected one is practically useless from atrophy, even if
it is not devoid of tubular structure. Traction is of little serv-
ice, as manipulation tends to increase the sensitiveness of the
organ.
Simple umbilical and inguinal hernia should receive early
attention, as, contrary to the rule in adults, a cure can often be
effected during the first year of life by the persistent use of a
truss. In young infants I prefer the hard-rubber variety as
more cleanly. The instrument should be applied during the
first few weeks of life and continued for one or more years.
The treatment of strangulated hernia does not differ from that
in the adult, but, in obstruction of the bowels, intussusception is
so commonly the cause of the blockade that, unless violent peri-
tonitis is present, laparotomy, with careful search for the invagi-
nation, offers the best hope of relief, and, I am glad to say, is
rapidly growing in favor.
Meningocele, encephalocele, and spina bifida are complaints
that will early require the surgeon's attention, or at least his ex-
pression of opinion and his prognosis. If attached by means of
a narrow pedicle, constriction with an elastic band is feasible,
but, unfortunately, this pedicle is but seldom found. Injection
of iodine, following tapping, is rarely successful, yet is worthy
of trial in so hopeless a task. In a large hydrorrhachis of the
lumbar region, lately under my care, which resisted pressure,
tapping, injection, and constriction, I was slrongly inclined to
excise the thin sac and attempt a plastic operation by drawing
in toward the median line two flaps of skin from the lumbar re-
gion, leaving the vacancies to granulate. Soon after a consulta-
tion, in which I was dissuaded from my attempt, the tumor rup-
tured spontaneously and death occurred in two days, although
frequent tappings had never produced any nervous symptoms.
I had then never seen a record of such a plan of procedure, but
only last week I noticed in the "Journal of the American Medi-
cal Association," vol. iv, No. 17, p. 460, that Mr. Robson had
performed this operation with successful results in two out of
four cases. Strict antisepsis was enforced.
Cephalhmnatomata are usually easily distinguished from en-
cephalocele or meningocele, and also from the simpler tumor,
caput succedaneum, the latter being exterior to the periosteum
and more doughy. The blood in a cephalhaematoma is always
confined between the pericranium and the bone substance, and
increases until the second or third day. The hardened ridge
around the border of the tumor may give the sensation of an
opening in the bone, but the orifice in meningocele is rarely as
large as the base of the swelling mentioned. The peculiar crack-
ling feeling upon pressure at a later period is due to the new
bone deposits beneath the periosteum. Absorption so generally
takes place in three or four weeks that aspiration or incision is
unwise, even though antisepsis be thoroughly practiced, unless
in exceptional cases when suppuration is certainly present.
Hare-lip will early require the careful study of the surgeon,
situated as it is upon the portion of the body that is most re-
garded from the cosmetic point of view. Its proper relief there-
fore becomes not only a matter of surgical skill, but of surgico-
artistic skill. The time for the performance of the operation is
a point upon which there is a wide diversity of opinion. My
rule is to relieve the deformity within three or four days if it
interferes with the proper nursing of the child. Practically I
must confess, however, that by the end of the operation the
milk has left the mother's breast, unless there is some other
baby to maintain the flow. My preference is to wait about
three months, until a full, vigorous activity of growth and cell
action is at work, and before the process of dentition has com-
menced. This period is selected not only tor the reason men-
tioned, but also because the child can not use its hands so freely
as at a late period of infancy, thus avoiding risk of injury. In
one patient a year old, diphtheria appeared on the day following
operation, and in his convulsions all the pins were twice torn
entirely from their fastenings aod the fresh wound became im-
plicated. In spite of such complication, an excellent result was
obtained by holding the parts in position for days with adhesive
plaster cut in the form of a triangle, sufficiently large to cover
at its base the area from in front of the ear to the corner of the
hyoid bone, with its apex prolonged at the width of the upper
lip to meet a similarly shaped piece from the opposite side.
These sections were united by a small elastic ring which main-
tained a constant pull upon the tissues of the chock and con-
trolled spasmodic muscular action. In fractious children I have
now discarded pins and have substituted catgut sutures for the
mucous surfaces, which, if of small size and tied in three knots,
will remain in position until union occurs. For the skin edges
I use carbolized interrupted silk sutures, my reason for stitch-
ing the surfaces separately being that there is less linear depres-
sion of the cicatrix, and less constriction of tissues is thereby
exercised than by pins and the figure-of-eight, while, if each
set penetrates half-way through the lip antero-posteriorly, the
sphincter is thoroughly controlled. One of the stitches should
pierce the coronary arteries. To prevent pouching of the flaps
or separation of the deeper parts by oozing, horse-hair drainage
78
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jouk.,
for a few hoars answers the best purpose. Additional control
of muscles should be given by adhesive plaster prepared as above
indicated or by strips, which should not only be applied trans-
versely, but, in order to prevent strain, should commence upon
the neck on either side, in front of the sterno-mastoid, near the
cornu of the hyoid, and run thence just above the angle of the
mouth across the opposite malar to the front of the ear. If
these are all put in position while the surgeon pinches the
-cheeks well together, he will find, upon releasing his grasp, that
the minimum of tension is exerted upon the stitches. A still
better plan is to have the nurse regulate this muscular action for
the first few days by pressure whenever the child cries or eats.
Only by securing union by the first intention can we hope to
have a narrow cicatrix ; hence I do not allow the child to suck,
as is the practice with some surgeons, but prefer spoon-feeding,
as producing less disturbance. For the same reason, anodynes
should be employed to control pain and keep the little one for a
few days in a quiescent state. The child should be in the best
possible condition physically, as quick union is desirable. To
avoid the marginal depression so commonly seen, and which is
inevitable if the simple inverted V-incision is used, I never sac-
rifice any portion of the paring, but, commencing the incision
at the apex of the cleft, stop it just before it reaches the border
of the lip, thus leaving a base of supply to nourish the flap
which remains on either side. These two flaps, when the parts
are brought together, project downward and form a fleshy
prominence : but, if stitched nicely together, will unite and,
from subsequent absorption during the next year, give a slight
projection. Even should this be larger than desirable, it is
far preferable to the ugly notch which can not be corrected,
since a simple scissor-cut will remove all redundancy and gire
a nearly normal lip. The same rule in regard to utilization of
tissue holds good in complicated cases of hare-lip when it be-
comes necessary to save as much of the alveolus as possible.
Broken or cut, it can often be worked to advantage in bridging
the chasm or supporting a fallen nasal septum.
If deft palate co-exists with hare-lip, an additional necessity
for early treatment is present, since the closure of the lip will
tend greatly to lessen the gap in the hard palate. Dentists
realize more fully than surgeons how slight is the pressure re-
quired to act upon a tooth or upon the alveolar process, but a
moment's reflection will convince any practical man that such
narrowing can be accomplished even if he has never witnessed
it. In these instances, as in hare-lip and many other deformi-
ties, neglect is often as much the fault of the physician as of the
family. An early operation upon the lip, strong pressure upon
the maxillary bones, followed by the use of a Hainsby's com-
pressor, will in a few years bring the cleft so close together that
a single operation will unite the edges.
These are the considerations which influence me in advising
that, while the lip should be closed early, the cleft-palate opera-
tion be deferred until the plan has been tested. Few children
from five to ten are tractable enough to endure the pain of a
staphylorrhaphy without ether, which is desirable, and I see no
particular harm in delaying the procedure until the latter pe-
riod, save that the unused or malused muscles will require a
longer period of education after closure. In a recent staphy-
lorrhaphy upon a boy of sixteen the letters of the alphabet
could, however, all be correctly pronounced in three weeks ex-
cept the k and hard-c sounds. If a good velum and uvula can
be secured by union, the hard palate can be admirably assisted
by an obturator. Only last week, by preliminary touching and
the use of cocaine, I was able, in a child of five years, to make
the parings without pain, and thus avoided anaesthesia until all
haemorrhage had ceased, ether being employed for stitching
-only.
Tongue-tie is a condition that exists more frequently in
imagination than in reality, yet the operation for its relief
need be no more than the most trifling nick of the fraenum,
the finger completing the work. If the organ can be pro-
truded to the red border of the lip, no operation is neces-
sary.
Club-foot is a deformity which is frequently neglected, not
alone from the apathy of parents, but, as is shown by the cases
which come under my notice, far more frequently from the in-
comprehensible advice of the family physician, who has coun-
seled that "nothing shall be done for the present." Weeks
slip away into months and months into years, during which
time one set of muscular fibers and one set of ligaments have
become elongated, while the opposite ones are atrophied, con-
densed, and shortened. Bones, too, have become distorted and
wedge-shaped, and the difficulties have, of course, increased
fourfold with each advancing year. I have never been able to
see any reason why delay should be countenanced a single day
after birth, since manipulation and subsequent fixation can easily
be accomplished at the first dressing of the child. I know of no
words sufficiently strong to characterize such neglect of duty as
is seen in numerous instances. Twice in the last three days
have I had this matter brought before me by parents who have
come to the office and who have given as the reason of their
inaction that the physician had directed them to wait. Even
before the age for walking, great condensation of tissue will
take place and increase of deformity will occur from simple
pressure of clothing, but, as soon as the weight of the body is
brought to bear upon these misshapen members, the change will
be rapid. The secret of the cure of club-foot lies not in opera-
tion, but in careful attention to all the means of relief. At the
first hour of birth, as I have said, manipulation should be com-
menced by bringing the foot from the abnormal into a normal
position, or as near it as possible, and confining it there by
wood, felt, binder's board, or leather splints rightly adapted.
At the next visit, leather, gutta-percha, or, preferably, printer's-
blanket cinctures, should be laced upon the foot and leg, and
connected by an elastic strap. The two-ply printer's blanket,
with its rubber face, does not slip, even when applied with only
moderate tightness, thus being superior to other materials.
Hook-eyelets are easily inserted by any shoemaker, and the
lacing need not impede circulation. Manipulation can be prac-
ticed twenty times a day without taking off the apparatus, while
removal at night gives opportunities for massage, frictions, etc.
If co-operation of parents is wanting, plaster of Paris can be
employed with excellent advantage for fixation, a gain being
effected with each month's renewal of the dressing. Leather,
felt, sheet-lead, and silicate of sodium are of use, but do not
permit removal for manipulation, and are, therefore, inferior to
the bands already mentioned. These bands, which permit of
constant elastic traction day and night, are very inexpensive if
remnants are bought. Their use puts the successful early treat-
ment of any case of talipes into the hands of the ordinary prac-
titioner for the first few months of life. In cases which are of
a severe type, a subsequent operation is usually necessary, but
the manipulation which has been practiced up to the time for
tenotomy stretches condensed tissues and increases nutrition so
that relapse after division of the tendons will not occur, if the
same measures are continued subsequently. Failure after te-
notomy is nearly always due to the neglect of manipulation.
The special form of apparatus is far less important than a strict
attention to details. The chief advantage of the shoe which I
employ lies in the fact that it permits manipulation and stretch-
ing without removal, owing to its flexible sole-shank of upper-
leathers, which acts_ perfectly as a ball-and-socket joint, the
force being exerted by an elastic strap operating upon the foot
July 18, 1885.1
PROCEEDINGS
OF SOCIETIES.
79
through a catgut cord passing through an eye attached to the
upright. The eye-bearing arm is ordinarily constructed with
too little an outward bend. If I can control the patient I rarely
operate until I have the tissues thoroughly stretched, but if the
foot can not be placed upon its plantar surface at eight or nine
months — that is, when the age of walking arrives — tenotomy
should be delayed no longer, since each step will increase the
deformity. In operating, I divide every tissue that interferes with
perfect straightening, whether it is tendinous or fascial. The
tendon of the posterior tibial is an exceedingly difficult one to
sever in a fat infant with a poorly developed heel. The punc-
ture should be made just below the malleolus, and, having
placed the back of a tenotome toward the artery, division can
be safely made. Tenotomes, as found in the shops, have too
long a cutting surface for infantile work, as the sharp edge will
frequently enlarge the external wound unnecessarily. It is my
practice to leave the tendo Achillis until the end of the opera-
tion, in order to gain its fixation power in the leverage required
for stretching the parts into position, a procedure which is best
accomplished at the time of operation. The amount of power
which should be employed in this process is governed by the
degree of resistance and the caution of the surgeon, special
care being taken that the force is expended only on the resist-
ant tissues. In tbe class of cases with which this paper deals—
namely, those of young infants — it is scarcely possible that tar-
sectomy could be called for, although an English surgeon has
thus operated upon a sixteen-months-old babe. I now use the
gypsum dressing entirely after tenotomy, not only since it is
less expensive, but chiefly because it holds the foot and heel in
much better position than is possible by any apparatus, and is
less liable to produce sloughing, because the pressure is exerted
over the entire surface. The instances where plaster produces
a slough are always due to faulty application, mainly caused by
some indentation produced during the setting process. If the
bandages are smoothly and rapidly applied (salt having been
added to the water in which they are immersed), the surgeon
can, by grasping the knee, hold it steadily in place, while, with
the palm of his other hand placed against the plantar surface
of the child's foot, complete rectification can be maintained
until the plaster hardens without danger of depressing any re-
gion of the cast. A dossil of curled hair or cotton placed over
the ball of the great toe and the prominence of the cuboid or
astragalus, and confined in position by the flannel bandage en-
veloping the foot, will also assist in averting any harmful press-
ure.
I can not too strongly emphasize my appreciation of plaster
of Paris in the treatment of fractures in infants, giving, as it
does, a perfectly adaptable material, and yet, when hardened,
securing an immobility of the injured part that permits free
handling, provided the articulation both above and below the
injury is included in the dressing. This is feasible even in frac-
tures near the hip, since the splint can be made to encircle the
thorax, and thus prevent the great motion that is always pres-
ent if only the pelvis is fixed. No risk of injurious swelling
need be feared if a flannel bandage or a thin layer of cotton is
first applied to the limb. It is better to saw open a dressing at
the end of two weeks, and either tighten it or apply a new one.
Silicate and other rigid dressings harden so slowly that dis-
placement may occur during the process. The fractures occur-
ring during birth are often overlooked for several days, and the
fact that the child moves a particular portion of its body freely
is not proof that lesion of bone has not occurred. I have seen
several instances of fractured clavicle in which tho child in-
dulged in most vigorous movements of the arm. These collar-
bone breaks are quite common, either from falling out of bod,
from careless handling, or from the playful jerking of other
children. The under-waist of an older child, placed in proper
position over the sound arm and pinned tightly around the
body so as to include the injured member, often keeps in place
better in fat babies than a Velpeau bandage, especially if the
hand is secured with a loop. Borated cotton should be placed
in the axilla.
Green-stick fractures are best treated by etherizing the child
and slowly straightening the bone by hand-pressure. Even
should complete solution occur, the result will be good. A
slight curve can be reduced by a splint and bandage. Separa-
tions of epiphyses are practically fractures, and should be treat-
ed as such.
Dislocations do not differ from similar injuries in adults,
save that they are even more readily replaced by manipulation.
The resultant deformities of infantile paralysis are numer-
ous, and are frequently passed over by both physician and pa-
rents, under the erroneous impression that nothing can be done
for the relief of these poor weakened members. Recognizing
that restoration is best accomplished by massage, electricity,
etc., and particularly by action, it is my rule never to assist a
muscle if it is capable of permitting locomotion, or unless de-
formity is being produced by non-support. The following are
the considerations that determine the necessity for apparatus :
If a bone is bending, an articular surface becoming distorted, a
ligament yielding, or muscles becoming atrophied from exces-
sive stretching, or if, by applying a support, the child can be
made to walk, then I always order an apparatus which shall not
take the place of the enfeebled muscles, or put them in splints
at rest, hut which shall reuder just enough resistance to enable
them by contraction to accomplish tbe desired purpose. If
rigid steel is used, they will soon relinquish their attempts at
assertion of power, and enfeeblement will increase. By ajudi-
cious adaptation of mechanical appliances, many who are now
condemned to chairs and beds can be placed upon their feet.
The advisability of tenotomy will depend upon the benefit to be
gained by such a procedure. In many cases it will assist great-
ly in placing limbs in proper position for locomotion, and for
this reason its mechanical effect should be thoroughly studied.
My observation leads me to believe that it is employed too sel-
dom. The excision and shortening of tendons by suturing is
often of advantage. Any irregularity in the length of limbs
should be counteracted, lest lateral curvature result.
N~cevi, if situated upon exposed portions of the body, must
be cured early in life if rapidly increasing in size, and in the
majority of cases should be attended to before six months is
reached. The question of excision, ligature, subcutaneous liga-
ture, injection, electrolysis, or sun-heat, will depend upon situ-
ation, size, etc.
Webbed finger* and supernumerary toes and finger* will yield
smaller resultant scars if operated on during the first half-year
of life.
Wry-neek may follow injury to the spinal accessory nerve
during labor, or it may be found as a result of some of the ex-
anthemata. If resistant to local and constitutional remedies,
myotomy should be performed at the end of a year.
Spinal caries in young children can be retarded by placing
the sufferer upon its back between two sand-bags, while pas-
sive motion is employed to develop muscular power. A jacket
or cuirass may be added if bone-death is rapid, or if difficulty
of retention Is experienced. Horizontal extension is rarelj ne-
cessary. I have occasionally seen lateral curvature in weak
infants caused by the mother's habit of always holding them in
one position, the reversal of which custom has, together with
constitutional remedies, completed a cure. It may also be the
result of a rhachitic tendency, which will necessitate the appro-
priate medicinal and hygienic management. Simple posterior
80
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jode.,
curvature, aud also lordosis, are sometimes found, and should
be closely watched, as other symptoms of that disease of mal-
nutrition, rickets, may soon present themselves. Dorsal decu-
bitus should be maintained until the proper treatment has had
time to strengthen the child. Rickets, fortunately, is seen upon
this side of the Atlantic far less frequently than on the eastern
shores, and, I am thankful to say, is seldom found in Philadel-
phia even as compared with New York. In fifty thousand
cases in our hospitals, I find that fewer than fifty are enumer-
ated under rickets and its results, including knock-knee, bow-
legs, etc. Its onset is usually within the first six months of
life, but, unfortunately, many cases are not brought to the
notice of the surgeon until one or two years have elapsed and
great deformity has already resulted. When pronounced, the
most rigid care should be taken to prevent the distortions, from
which no bone in the body seems exempt. The effects upon
the female pelvis are most disastrous, as life is thereby endan-
gered. The recumbent position is the only safe one, and must
be maintained until the general remedies have time to act, pas-
sive motion meanwhile taking the place of active. The tibial
curves are the most common of defects. Very slight bowing is
sometimes corrected in the growth of the individual, but we
have no more right to expect that such a result will spontane-
ously occur 'than that a crooked tree will be blown into the
upright position by chance winds. The proper means should
always be used to compel rectification. If the bones are
spongy, much can be expected from manipulation, pressure,
and apparatus properly constructed. During the first two
years of life we may confidently hope to accomplish a good
result by such means, but in later childhood or adult life, if the
deflections are great and the bones rigid, and especially if the
curve is anterior, but little can be gained by these means, and
osteotomy is the more certain and speedy means of relief. The
risks of this operation, if done antiseptically, are but very slight,
as the case, if sealed, becomes one of simple fracture. Plaster
of Paris, again, gives us the best means of fixation after opera-
tion, and is very comfortable to the patient.
I approve of instruments in lateral bow-legs, but, when they
fail to secure straight limbs in the class of cases above men-
tioned, I firmly advocate operation. The deformity, if allowed
to continue, is not only unsightly, but also interferes greatly
with the locomotive powers. It is not true that a bow-legged
man is strong. He has, on the contrary, to use his limbs at a
disadvantage, and, if he is vigorous, it is in spite of his com-
plaint.
The question of tracheotomy in young infants, with whom
our present discussion chiefly deals, is one demanding the
gravest consideration, whether the dyspnoea originates from
diphtheria or from true croup. So fatal are the results that
the mortality in babes below the age of six months is placed by
some writers as high as ninety-five per cent., and, even taking
all under two years, we can not expect to save more than from
ten to fifteen per cent. When we consider, however, that some
English writers place the mortality of croup without operation
at ninety per cent., we can not believe that the operation has
increased the number of deaths. Moreover, when cases are
taken at the most favorable age and the most favorable condi-
tions, we can scarcely hope to save more than twenty-five per
cent, of all patients operated on. I have spoken thus in regard
to prognosis since some surgeons absolutely condemn the em-
ployment of tracheotomy for these young patients. I can not
feel, however, that they are absolutely hopeless, and, if surgery
can relieve them from the horrid death by suffocation, we should
not hesitate to give them the aid of science, although a true
tracheotomy is well-nigh impossible in a young, fat infant, owing
to the exceeding shortness of the trachea and the great size of
the thyroid body. It is usually best to do an inferior lar-
yngotomy (or cvieo-thyro-laryngotomy), making the opening
through the crico-thyroid membrane, and also through the cri-
coid if necessary. The risk of haemorrhage is thereby greatly
diminished, since, while the crico-thyroid arteries may be cut,
they will be far less troublesome to secure than the vessels
about the thyroid body or the middle thyroid artery, which
often lies in front of the trachea. Again, the innominate artery
may rise high in the neck, or a wound of a vein near the innomi-
nate may speedily kill the little one, as has happened in a num-
ber of instances, even when the operator has been experienced.
The fact that surgeons who have opened the windpipe several
hundred times look upon this operation as an exceedingly diffi-
cult one is proof that the utmost care is necessary. The danger
of wandering from the median line may be partially obviated
by having the child's head kept perfectly straight and by plac-
ing the body in exact line with the table. The trachea is some-
times missed because it has not been thoroughly cleared of every-
thing before attempting to open it. The puncture should be
made firmly but guardedly. The size of an infant's trachea will
surprise one who has never studied it. Although I have given
large and special study to the anatomy of childhood, both from
the cadaver and clinically, my first tracheotomy patient died on
the table before I could insert the tube, my error being in try-
ing to push the cannula too far back. Unless the urgency is
great, ether should be given in moderate amount and the opera-
tion carefully performed. A plunge into the trachea is never
good surgery ; in infants it would be worse than folly. If a
circular piece is taken from the crico-thyroid membrane and the
cricoid, and a pilot used, introduction will be rendered more
easy. In fat necks, the windpipe may be brought nearer the
surface by extending the head far backward and by grasping the
tube on either side and dragging it forward. If fixed thus in
the median line and retained continuously by an assistant, much
time will be gained. In a recent case I found it wiser to go
above a large thyroid body, eveD in a five-year-old child, and
insert the cannula in the crico-thyroid space. There was after-
ward a slight burying of the upper edge of the plate, owing to
its high position, but a strip of sheet-lead obviated this diffi-
culty. To arrest the venous haamorrhage, just before puncture,
hot-water sponges answer admirably. After operation, the
temperature of the room should be kept above 80°. I have
never opened the larynx to remove a foreign body in a very
young child, but the universal habit of making the mouth the
general receptacle of everything makes the introduction of such
substances exceedingly probable at from one to two years.
Foreign bodies in the nose, which can not be seized, if not
removed by sternutatories, should always be sought for with
the aid of anaesthetics. In the ear the opposite mode holds
good, since consciousness of pain will often prevent an unskilled
practitioner from doing great injury to the membrana tympani.
Joint diseases are best treated by recumbency, with fixation
or extension.
Excisions are rarely performed at this early age, and need
not therefore be discussed.
I omit strumous and syphilitic diseases and a score of other
conditions, which might well detain us for hours, since time
forbids.
I have thus, gentlemen, hastily touched upon only the more
frequent of the surgical maladies met with in daily practice
among infants. Many of the suggestions may be already famil-
iar to you, but even the brief mention which I have been
allowed to bestow upon each subject may possibly have served
to revive in your minds old and forgotten experiences, and thus
be helpful. You will, at least, see that the field is a wide one,
and that results are most encouraging.
July 18, 1886.J
PROCEEDINGS OF SOCIETIES.
81
MEDICAL SOCIETY OF THE COUNTY OF KINGS.
Meeting of May 19, 1885.
(Concluded from paye $.9.)
The Eradication of Syphilis during the First Stage by
Surgical Means. — Dr. A. H. P. Leuf read a paper on this sub-
ject. [See page 36.]
Dr. F. N. Otis, of New York, said that the treatment of
syphilis was a subject in which he was very much interested,
and especially as to the point which was announced for discus-
sion this evening, namely, the eradication by surgical means.
It was a subject which had interested the surgical world for a
number of years. Auspitz and Kolliker, of Vienna, he believed,
were among the first who had claimed success in eradicating
syphilis by excision of the initial lesion, and reported a large
number of cases — something less than half a hundred. Others
had supported the claims of Auspitz by citation of similar suc-
cess both in this country and abroad, but it was still a mooted
question whether or not syphilis could be eradicated by excision
of the initial lesion. It was well understood and had been
ably expressed by the author of the paper that the invasion of
syphilis was a gradual process, that the chancre, or initial lesion,
was the first manifestation, and the second observable manifes-
tation was the enlargement of the glands in connection with it,
wherever situated. There were, however, a number of points
about which mistakes might arise in taking the paper exactly in
the terms in which it had been read. For instance, in describ-
ing the chancre as an " ulcer " we had to recognize that the
chancre was not an ulcer primarily, and was not necessarily an
ulcer at all, and that the processes of syphilis were not de-
structive. There was always destruction in chancroid, and this
was one of the differences between chancre and chancroid.
Chancre might be acquired without any recognized abrasion or
breach of the surface. The virus might enter through a rup-
tured hair follicle. Syphilis might enter through some unob-
served wound, which healed promptly, no destruction taking
place, and yet the person would have syphilis just as certainly
and as severely as if the introduction of the syphilitic principle
was followed by a typical Hunterian chancre. It was not a pro-
cess of destruction, but of proliferation, from the very begin-
ning. Proliferation and aggregation of cells, wherever it com-
menced, were always its characteristic, whether great or small.
Now, excision of these cells had been asserted to relieve the
system of danger of syphilis, they being assumed to be the
starting-point. It had been demonstrated by histologists beyond
cavil that this difficulty, instead of being the result of a general
instantaneous infection, always commenced at a given point,
and that there was a contagium introduced through a lesion
of the skin, or mucous membrane, which traversed the system
slowly through the lymphatic spaces and vessels. Having, then,
its beginning at a certain point, if it could be determined that
it had not gone much farther, we might hope for its eradication
by surgical procedure. But the syphilitic principle, so far as
we know anything about it, was a cell which possessed the
power of motion, the power of traversing tissue, and it had
also the power of generating other cells having equally the
power of traversing tissues. They were not quiescent, but were
always moving to a greater or less extent, and in a short time —
a few days or, perhaps, weeks — they would have traveled along
the lymphatic vessels and have established local points of pro-
liferation in neighboring lymphatic glands, thus accumulating,
so that tho glands became emphatically identical with the chan-
cre— the initial lesion of syphilis. They contained the samo
vitiated cell material. Inoculations with the cell material from
these glands would produce syphilis in a healthy person as cer-
tainly as with the secretion of the typical chancre. We had,
then, these cells traversing lymph-spaces and vessels ; and it
had been maintained, on examination, that they often clung to
the sides of the lymph channels on their passage through them,
and in this way often blocked up such channels completely for
the time being. It was not unusual to see a line of lymphatic
vessels extending from the initial lesion to the glands in the
groin distinctly marked by an induration caused by accumula-
tion of newly generated cells, and, if this be the case, it seemed
impossible, then, that by excision of the initial lesion alone
syphilis could be cured. In order to prevent its passage into
the system, we must eradicate every infected cell, not alone the
initial lesion, but those which had passed from it into the lymph-
spaces, vessels, and glands in connection with it. This, of course,
would necessitate an amount of surgical interference which
would hardly be justifiable under the circumstances. The facts
were, so far as he knew anything about them, that as yet no
case had ever been cured by a simple excision of the initial
lesion, for the reason that the cells had got beyond the reach of
the surgeon's knife before he had ascertained the presence of
this accumulation. He had himself excised perhaps twenty or
thirty chancres, and carefully kept track of the patients after-
ward. In some of these cases no positive secondary symptoms
had followed, but there was always a doubt about such cases
whether the diagnosis had been correct or not. In these cases
he had traced the source from whence the disease had been
acquired ; but he assumed, from their history and appearances,
that they were genuine cases of syphilis.
It would not surprise him very much to see some of these cases
of excision, in which no secondary manifestations had followed,
develop what was called tertiary lesions ten, fifteen, or twenty
years hence. We saw so many cases where there had been no
secondary lesions apparently, and yet the sequela showed that
the disease did exist. We must recognize this fact, then, that
there were a great many patients who had the secondary stage
so slight that it escaped observation, and this was a source of a
great deal of mistaken diagnosis, and assertions of success in
treatment which had no real foundation in fact. Among other
points of special interest alluded to in the paper just read had
been that of hereditary syphilis. It was a question of great
interest. He would like to say a few words in regard to this
subject, and especially to look at it from the point of view
which was taken by that most distinguished syphilographer, Mr.
Jonathan Hutchinson, of London. He said that syphilis was
not an hereditary disease ; and he said distinctly that syphilis
was no more hereditary than small-pox, and was hereditary in
the same way as small-pox. It was the disease, and not a dia-
thesis, that was communicated. This would be found in his
article on syphilis, etc., published in London, in 1884, in a little
work entitled " The Pedigree of Disease." This position was
certainly a very startling one in view of the doctrine heretofore
held by the profession at large. For his own part the speaker
was quite willing to accept it. In point of fact, the views which
he had held and advocated, first in his "Physiology and Pa-
thology of Syphilis," published in 1880, made such a conclusion
the logical sequence of the position assumed in that work.
Afterward, in his work on " Genito-urinary Diseases and Syphi-
lis," published in 1883, there occurred a chapter on the syphilis
of infants and the so-called hereditary syphilis in which the
question was considered from tho standpoint of a gradual
material syphilitic infection through a diseased cell or germ
as opposed to the mysterious instantaneous doctrine held by
most authorities, and the only logical deductions from these
promises fully warranted the statement (first made by Mr.
Hutchinson in 1882) that syphilis was never the result of he-
reditary transmission. It seemed to him that there were
82
MISCELLANY.
[N. Y. Mkd. Jour.,
many things that hitherto had not been understood which
pointed to the truth of this teaching. For instance, syphilis
was said to be communicated by the male parent to the
child by heredity. This was accepted by almost all authori-
ties. Now, it was likewise asserted by all authorities that
the physiological secretions — sweat, milk, saliva, mucus, urine,
tears, and semen — did not contain the contagium. The latter
was particularly mentioned. They all mentioned it. If we
referred to any of the transatlantic authorities, we should find
this statement confirmed. Our own authorities — Bumsted,
Taylor, Van Buren, and Keyes — all stated distinctly that it was
well ascertained and accepted that the semen did not contain the
contagium of syphilis. If that was the case, it would be inter-
esting to know how they would answer the question as to how
the male had access to the ovum — how the male could com-
municate syphilis to an embryo or to an unborn child. This
was a question which it might be well to think of. The facts
probably could be shown to be that whenever the ovum, or
foetus, or child had syphilis — syphilis that had been acquired in
utero — the mother had first been infected; that, if due to the
male parent, he must necessarily have given the disease first to
the mother, and she in turn to the child. Now, there was a
curious fact spoken of by Diday. He said it was a well-known
law that no woman could communicate to her infant a syphilis
which she had acquired not to exceed two months previously
to the birth of the child. So certain was Diday's belief in this
law that he said he was willing to give to a healthy woman to
nurse a child of a woman who bad acquired her disease not
more than two months previous to her delivery. Now, there
were two months during which it was accepted as a clinical
fact the child is safe. If the mother acquired her initial lesion
only two months previous to the birth of the child, that child
could not acquire syphilis in utero. The question at once arose,
Why was this ? It was because the syphilitic poison was not
yet in the blood of the mother, that it required two months
at least for it to get into the blood of the mother, and then only
could she communicate it to the embryo or to the child. This
also proved what had been stated in the paper of the evening
in regard to the gradual infection of syphilis. Before this was
understood, this rule of Diday could hardly be comprehended.
Dr. Baetlett, of Flatbush, remarked that all physicians
having a large experience with the criminal classes knew but
too well the moral, intellectual, and physical misery and degra-
dation entailed by syphilis. In view of this, he thought that,
in certain cases, both for the good of the criminal and the pro-
tection of society, a more radical and serious surgical operation
would be justifiable than the one proposed. The principle of
heredity was so strong that society had the right to protect
itself in these cases by preventing the possibility of procreation.
Dr. George R. Fowler took exception to the statement
made by the essayist that tertiary symptoms of syphilis almost
always occurred. The speaker was of the opinion that syphil-
ographers of the present day maintained that tertiary symptoms,
and particularly those of a severe type, were rather rarely met
with. He further believed that it was a growing impression
that syphilis in its protean form was, so to speak, " running out."
The syphilis of to-day was not the syphilis of one hundred years
ago, and many of the cases which were supposed to have escaped
syphilis because of excision of the initial lesion were cases
in which possibly no manifestation of the disease would have
occurred at all. He alluded to the fact that in Auspitz's experi-
ments, in those cases in which the characteristic sclerosis reap-
peared at the point where the chancre had been excised, con-
stitutional syphilis occurred irrespective of the existence or
non-existence of indurated glands prior to the excision. This
must make it appear that there was a stage of the disease dur-
ing which the condition of the glands, so far as we were able
to determine it, had very little, if anything, to do with the de-
velopment of the sequelae, if the subsequent stages in their de-
velopment might be so denominated. Dr. Leuf had said it was
well proved, although not generally known, that self-inocula-
tion was possible prior to systemic infection ; and that brought
us at once to the important point in the discussion of the ques-
tion of the excision of the initial chancre together with the in-
durated glands. The cases cited by Auspitz, in which con-ti-
tutional syphilis occurred in spite of the fact that no induration
of the inguinal glands took place prior to such development,
suggested the possibility of channels of infection other than
these lymphatics. He recalled a case in which a surgeon re-
moved a tumor of the testicle, and, while excising some indu-
rated glands in the groin, accidentally pricked his thumb. In
due course of. time a syphilitic chancre made its appearance at
the site of the little wound, and this in its turn was followed
by constitutional syphilis. Although the patient had denied
venereal disease when admitted to the hospital, yet he acknowl-
edged to the surgeon subsequently that ten years before he had
had a sore upon his penis, for which he did not seek advice,
and that the indurated glands in the groin had existed since that
time. No other manifestation of the disease had ever occurred.
If it could be supposed that this patient had kept the virus stored
up in these indurated glands for ten years, then we could see our
way clear, in a certain proportion of cases, to a hope of benefit
to be derived from excising such glands as early as practicable.
Dr. Lecf, in concluding the debate, saw, in reference to the
remarks of Dr. Otis, that that gentlemen had entirely misun-
derstood him. He had expressly stated that the primary lesion
was not an ulcer. With reference to the implication of the
lymphatic vessels, if they were at all involved, perhaps whether
they appeared to be involved or not, it might be most proper
to excise them. As to the justifiability of the operation, he
would say, if it was justifiable to extirpate a whole breast, to dis-
sect away all the fat and superficial fascia down to the pectoralis
major, and clean out the whole axilla because there was a little
nodule in the breast, it certainly ought to be justifiable to re-
move from the end of the penis a small sore, and even a few
glands and lymphatic vessels running therefrom. With refer-
ence to Dr. Fowler's observation that syphilis was not so bad
as it was one hundred years ago and was "running out," the
speaker thought if that were so the operation might be justi-
fiable on the ground that by its means it might be made to " run
out" so much the quicker, and he thought it was not wise to
excise the lesion without scooping out the glands also. If these
lymphatic vessels and everything in their immediate vicinity
were excised, "cleaned out," he thought an additional safe-
guard would be effected, and he did not think the operation
very dangerous. A surgeon of the enthusiasm of Dr. Fowler
ought not to see any particular danger in it. Dr. Fowler had
also referred to the possibility of there being some other chan-
nel of absorption on account of the non-infection of the glands,
apparently. There seemed to be no other channel except the
blood, and the speaker thought that idea had been refuted in
the paper. If it was not through the blood, it must be through
the lymphatic or other channels that he knew not of.
Ultstjellana .
The Ninth International Medical Congress. — Speaking of the
action of the enlarged committee, the " Boston Medical and Surgical
Journal " says :
July 18, 1885.]
MISCELLANY.
83
" The committee did the work expected of it, and with less malice
than would have been possible, but with sufficient thoroughness, we
fear, to put an end to the prospects of a successful and creditable in-
ternational congress, and adjourned to meet in St. Louis on the first
Monday in May, 1886. The rules were amended so as to confine mem-
bership to the constituency of the American Medical Association. The
American members, it is decreed, shall consist of delegates from the
American Medical Association, and from medical societies in affiliation
with it, each of these societies being entitled to one delegate for every
ten members. The number of sections was reduced from nineteen to
sixteen, and the presidents of sections are no longer ex-officio members
of the General Committee.
" Dr. H. I. Bowditch, of Boston, was dropped from the list of vice-
presidents, Dr. A. Jacobi from the presidency of the Section of Diseases
of Children, Dr. Lefferts from that of Laryngology, Dr. H. P. Bowditch
from that of Medical Education, and Dr. H. D. Noyes from that of
Ophthalmology. Numerous changes and additions were made in the
vice-presidents and members of council of the different sections. Those
honors are issued as plentifully as fiat money after a coup d'etaf, and
the various geographical divisions of the country are impartially be-
sprinkled with them. A publication of the full list would require
much space ; and, as this is already the second long list made public
within a few months, as the refusal by many prominent men to serve
as officers under existing conditions makes certain the appearance of
other revised lists, which may eventually end in no list at all, we con-
tent ourselves with referring our readers to our news columns for the
present organization of the Congress and for changes in the presidents
and vice-presidents of sections. In the same columns will also be
found a report of the action of prominent physicians in Philadelphia
and Boston connected with the organization of the Congress. These
refusals to accept office in the present organization will doubtless be fol-
lowed by others.
" These gentlemen proposed to aid and participate in the discussion
of questions of medical science, not of medical ethics, medical politics,
or of square miles of territory. There will, however, be more offices,
although less congress, for those who prefer such discussions and such
distinctions to a harmonious gathering of scientific men searching for
truth ; and we hope somebody may be happy, if it be only for a short
time."
In a very temperate article on the same subject, the " Maryland
Medical Journal " says :
" Looking at the work of the General Committee, it seems to us that
it has endeavored to make but few changes, and that it has performed
the disagreeable duty assigned to it by the association in an extremely
mild way. It has managed to make a few alterations in the chairman-
ship of the sections and to add a few college professors, formerly over-
looked by the original committee, to the sections. It has, however,
performed, in our judgment, the most stupendous work of supereroga-
tion ever exacted from a body of intelligent men. We are totally un-
able to see how the fortunes of the Congress have been a tithe benefited
by the changes made. On the contrary, it has suffered immensely in
the eyes of all unbiased thinkers by this unnecessary controversy
about representation on sections and ' New Code ' principles. As the
Congress now stands organized, we much doubt its ability to attract
that attention as a scientific body it was entitled to. How can those
men interested in pure science feel that same interest in the for-
tunes of an organization handicapped with contentions for offices and
ethics and weighted down with that ponderous body, the American
Medical Association ? It is truly an unfortunate circumstance which
has happened to impair the usefulness of the International Medical Con-
gress. While we still trust that wise counsels will prevail, that bitter
differences will subside, that men will consent to work together in har-
mony for the success of the Congress, it seems quite clear to us that
the Ninth International Medical Congress can not take the position it
would have assumed under its first organization. It is an apt saying,
Two wrongs can never make a right. The mistakes of the first com-
mittee— if such were made — have not been corrected by the present
committee. We fail to see how the few changes which have been made
in the officers of the Congress can do otherwise than impair its useful-
ness and drag it down to the level of a promiscuous social and semi-
scientific gathering. It is a sad commentary upon the status of the
profession in America that a petty squabble for a few positions should
have marred what had promised to be one of the most noted scientific
meetings ever held on American soil. What view our transatlantic
brethren will take of this status of the Congress it is not difficult to
surmise. We presume that the American Medical Association will en-
joy the banquet it has prepared to its own eminent satisfaction, while
the rest of the profession will look on from a distance. We can not
but deplore the present outlook, and profoundly trust that the final
result will be more satisfactory than present indications would seem to
warrant."
The "Peoria Medical Monthly" says:
"We believe the whole trouble has arisen from personal grounds
on the part of a few who were overlooked when the places of honor
were distributed. It was purely a fight of the 'outs' against the 'ins '
and, now that the ' outs ' have gained the field, the existence of the Con-
gress is jeopardized.
" It can not be claimed that the American Medical Association at
New Orleans represented the medical profession of this country, or if
the claim be made it is a laughable one. And it can not be denied
that the American Medical Association, with every similar body in the
country, is more or less ruled by coteries and cliques.
" The situation is a deplorable one for the good name of the medi-
cal profession in America. Our European brethren will hesitate to
attend the Congress at Washington in very large numbers, for they will
have reason to fear that the factional feeling and jealousies of certain
members of the ' rule or ruin ' party in the American Medical Associa-
tion will carry their fight into the Congress itself.
" What is to be done to remedy the trouble and preserve the good
name of the profession of America ? We do not know ; perhaps the
best thing that could be done would be to notify the Executive Com-
mittee of the last Congress that, owing to the war raging in the United
States, the next Congress should be held elsewhere, either in Europe or
Canada."
Science and Modern Discovery. — The present occupant of Sir Isaac
Newton's professorial chair at Cambridge University, Professor G. G.
Stokes, F. R. S., who is also secretary of the Royal Society of London,
delivered a remarkable address at the annual meeting of the Victoria
Institute, in London, toward the end of June. Professor Stokes gave
an important account of the progress of physical science during the past
quarter of a century, and, reviewing the results, specially noted that as
scientific truth developed, so had men to give up the idea that there was
any opposition between the Book of Nature and the Book of Revela-
tion. He said that for the last twenty years or so one of the most strik-
ing advances in science had been made in the application of the spec-
troscope, and in the information obtained with regard to the constitu-
tion of the heavenly bodies. The discovery that there were in these
particular chemical elements which were also present in our earth ex-
alted our idea of the universality of the laws of Nature, and there was
nothing in that contrary to what he had learned in Revelation, unless
we were to say, as the heathen did, that the God of the Hebrews was the
God of the hills and not of the valleys. Entering with some particu-
larity into the composition of the sun, he said this gave an idea of an
enormous temperature, since iron existed there in a state of vapor.
This was utterly inconsistent with the possibility of the existence there
of living beings at all approaching in character to those we had here.
Were we, then, to regard this as a waste of materials ? Might we not
rather argue that as in animals we ascended by greater specialization so
we could consider the differentiation of office in different members of
the solar system as marks of superiority, and could regard the sun as
performing most important functions for that system ? In fact, all
life on our earth was ultimately derived from the radiation of solar heat.
Referring to the doctrines of conservation of energy and of dissipation
of energy, he pointed out at some length how the sun, so far as we could
see, was not calculated for an eternal duration in the same state and
performing the same functions as now. We must regard the universe
on a grand scale, and then there was progress. If we contemplated
nothing but periodicity, perhaps we might rest content and think things
84
MISCELLANY.
[N. Y. Med. Joub*
would go on for ever as at present ; but, looking on the state of the
universe on a grand scale as one of progress, this idea obliged us to re-
fer to a first cause. He concluded with recommending that the Annual
Report of the society, read by Captain Frank Petrie, the honorary sec-
retary, be adopted. It showed that the number of home, American,
and colonial members had increased to upward of eleven hundred, and
that the Institute's object, in which scientific men whether in its ranks
or not aided, was to promote scientific inquiry, and especially in cases
where questions of science were held by those who advanced them to
be subversive of religion. All its members and one-guinea associates
received its Transactions free, and twelve of its papers were now pub-
lished in a People's Edition, which was to be had in many of the colo-
nies and in America. The address was delivered by Dr. J. Leslie Por-
ter, president of Queen's College, Belfast, the subject being " Egypt :
Historical and Geographical," a country with which he had been thirty
years intimately acquainted. Having referred to the antiquity of Egyp-
tian records, which in so many instances bore on the history of other
ancient countries, he proceeded to describe the various changes through
which that country had passed since its first colonization ; and, touch-
ing on its physical geography, concluded by giving the main results of
recent exploration. He said : " Were the Nile, by some convulsion of
Nature, or by some gigantic work of engineering skill — neither of which
is impossible — turned out of its present channel away up to Khartoum,
or any other point above Wady Haifa, Egypt would speedily become a
desert." No tributary enters the Nile below Berber — that is to say, for
the last thousand miles of its course. " The arable land of Egypt is
about equal in extent to Yorkshire." The White Nile, issuing from
Lakes Albert and Victoria Nyanza, is broad and deep, never rises above
a few feet, and supplies the permanent source of the river of Egypt.
" The other tributaries produce the inundation." Of these the Atbara,
from the mountains of Abyssinia, is the most fertilizing, as it brings
down with it a quantity of soil. The deposit of this soil is slowly rais-
ing the bed of the river as well as extending on each side ; for exam-
ple, on the plain of Thebes the soil formed by deposits has in thirty-five
hundred years encroached upon the desert a third of a mile, " while the
ruins of Hierapolis in the Delta, which once stood above reach of the
inundation, are now buried in a mud deposit to a depth of nearly seven
feet." In conclusion, he referred to Egypt and its present condition,
saying: "The commerce from the upper tributaries of the Nile, and
from the wide region of the Soudan, forms an essential factor in the
prosperity and progress of Egypt."
How to avoid Night Calls. — A story is going the rounds (who
started it we do not know) at the expense of the young physician who
is always so busy that he doesn't know what to do. " I have got more
business than I can attend to," boasted he to an old practitioner who
knew he lied. " I had to get out of bed five times last night." " Why
don't you buy some insect powder ? " quietly asked the old doctor. —
Medical Age.
Prizes for Electrical Appliances. — We learn from the " Chicago
Tribune " that the Mcintosh Company, of that city, received the first
medal for fine displays of electrical goods at the New Orleans Expo-
sition.
THERAPEUTICAL NOTES.
Glycerin as a Preventive of Trichiniasis. — Merkel (" Dtsch. Arch,
f. klin. Med." ; " Ctrlbl. f. kliu. Med.") relates the case of a man who
ate a portion, as long as one's finger, of a sausage in which living
trichinae .abounded. Twenty hours after the ingestion of the sausage
he was purged thoroughly with senna, and several specimens of the
trichina, non-encapsulated, together with fragments of the parasite,
were found in the dejecta. The next day he was given a tablespoonful
of pure glycerin every hour until fifteen doses had been taken. This
caused no unpleasant symptoms beyond thirst and a feeling of dryness
in the mouth, and the man escaped trichiniasis, while others who had
eaten of the sausage were attacked with the disease.
Naphthol. — Mr. W. J. Rigney, of New York, an analytical chemist,
writes to us as follows : " The extraordinary power of naphthol as an
antiseptic and disinfecting agent has been known for a long time, but
its disagreeable smell and the difficulty of preparing it in a pure state,
with the occasional toxical action of the crude naphthol, have been a
bar to its use as a remedial and antiseptic agent. Justus Wolff, a
chemist interested in coal-tar products, has recently succeeded in pro-
ducing it in a pure and odorless state, in well-defined crystals, and
states that its antiseptic action is much greater than that of carbolic
acid. Recent research has demonstrated that the toxic effects of crude
naphthol are due to the impurities it contains. Dr. Shoemaker, of
Philadelphia, as he stated in a paper read before the Philadelphia
County Medical Society, has conclusively proved the non-poisonous
character of the purified or odorless naphthol by taking large doses in-
ternally. It has no corrosive action on the skin, and will not injure
textile fabrics. As a remedial agent, it acts with greater efficiency than
carbolic acid, over which it has many advantages, and the fact of its
being absolutely odorless will make it a desirable substitute. It is ex-
pected that it will shortly be produced on a manufacturing scale as a
substitute for carbolic acid."
A Gargle for Chronic Pharyngitis. — The " Union medicale " attri-
butes the following formula to Bamberger :
Chloride of ammonium 75 grains ;
Honey of roses 760 "
Water 12$ ounces.
To be used several times a day, together with mustard foot-baths,,
the use of tobacco being prohibited.
Belladonna in the Treatment of Intestinal Obstruction. — Dr. T. J.
Hudson (" Med. Times and Gaz.") thinks that in these cases the best
way to use belladonna is to apply the extract to the abdomen with very
hot poultices, and to give one or two grains of the extract as a supposi-
tory every hour, or inject xhs °f a grain of atropine every two hours
until slight dilatation of the pupil is maintained. If the pain continues,
and is serious, an injection of -/•„- of a grain of atropine, with J of a
grain of morphine, is the best, as it combats depression and nausea.
Morphine alone often increases the obstruction by causing or increasing
nausea and, in the early stage of intussusception, preventing the bowel
from righting itself by its own muscular power. He adds the caution
that lime-water should not be given, as it decomposes atropine.
The Treatment of Seasickness. — " In our own person," says a re-
viewer in the " American Practitioner," " the bromide availed not, nor
would the Seidlitz stay down, but the Mellin's food was acceptable and
useful, while a good article of kumys was most grateful to the palate
and did much to allay nausea."
Hydrobromate of Quinine and Valerianate of Caffeine in the
Treatment of Malarial Poisoning. — Cerededo ("Gazz. degli Ospit.";
" Rev. med.") concludes from numerous experiments that the hydro-
bromate of quinine is preferable to the sulphate for the following rea-
sons : 1. Its activity is greater in moderate doses. 2. It acts as a nerv-
ous sedative. 3. It stops vomiting, a matter of special importance in
certain countries. 4. It readily brings about a favorable change in the
type of the fever. 5. Its bitterness is less marked. 6. It does not
irritate the intestinal mucous membrane, and produces neither consti-
pation nor diarrhoea. 7. It allows of the avoidance of too frequent
subcutaneous injections. 8. It diminishes the probability of relapse.
9. When once the paroxysm has come on, if it can not reduce its inten-
sity and duration, it should be administered in capsules, combined with
valerianate of caffeine. 10. Given in that way half an hour before the
paroxysm, it is capable of arresting the latter. 11. By combining the
two salts (fifteen grains of the hydrobromate and seven or eight grains
of the valerianate), we may check certain quotidian forms which are'
rebellious to much larger doses of the sulphate. 12. The action of this
combination of the two drugs, given in comparatively small doses, is
more powerful than that of any other salt of quinine in much larger
doses.
The Treatment of Epistaxis. — Introduce into the nostril, to a con-
siderable distance upward, a piece of fine sponge, cut to the size and
shape necessary to enable it to enter without difficulty, previously
soaked in lemon juice or vinegar and water. The patient is to be kept
lying on the face for a length of time, with the sponge in place. This,
says " Lyon medical," is the procedure employed by M. Siredey for con-
trolling epistaxis in typhoid-fever patients.
THE NEW YORK MEDICAL JOURNAL, July 25, 1885.
lectures an b |l b b r t s s * s .
LECTURES OJST
ELECTRICITY IN MEDICINE,
DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI-
VERSITY OF VERMONT, BURLINGTON,
By AMBROSE L. RANNEY, M. D., New York.
( Continued from page 63.)
Part HI.
Electro-therapeutics.
We have now discussed the essential points pertaining
to electro-physics and electro-diagnosis, and there remains
now for us to consider the uses of electricity in the treat-
ment of diseased conditions of various organs and tissues.
Before we pass to details of the practical part it may
be well for us to review in a general way some of the laws
which should govern us in applying electric currents to the
different tissues, and the objects to be attained by the em-
ployment of faradaism, galvanism, and static electricity.
GENERAL ELECTRO-THERAPEUTICS.
The rapidity and completeness of reported cures by the
use of electric currents upon living tissues during the last
quarter of a century leave no room for doubt that this agent
is particularly valuable in the treatment of paralysis, neural-
gia, spasmodic diseases, disturbances in the sensibility of
the skin, and many disordered states of the brain, spinal
cord, and peripheral nerves themselves. We have undis-
puted facts which prove also that blood may be coagulated
with safety within some aneurysmal sacs by the galvanic
current, that the life of the ovum may be destroyed in extra-
uterine pregnancy, that animal tissues may be disintegrat-
ed by chemical changes induced within them by this agent,
and that neoplasms may be removed without haemorrhage
by the cautery loop.
Our present ignorance of the molecular and nutritive
changes in tissues (as the cause or result of disease) renders
it impossible to do more than speculate upon the theory of
the therapeutical action of electricity in many cases ; but,
on the other hand, our empirical knowledge of these effects
is none the less valuable because we are unable to explain
them. The same criticisms would otherwise hold good in
reference to almost all of the drugs employed in medicine.
None of us know exactly how they produce their specific
effects.
Concerning speculation upon electrical effects on living
tissues, Erb remarks as follows : " What appears more nat-
ural than that neuralgia and spasms could be relieved by
the sedative action of the anode, with production of anelec-
trotonus, and that anaesthesia and paralysis could be cured
by the exciting action of the cathode, with production of
catelectrotonus ? But, apart from the fact that we are not
certain that an increase of irritability really occurs in one
group of cases and a diminution in the other, it must be
remembered that electrotonic action disappears very rapidly
after the cessation of the current, while the curative effects
of the current are more or less permanent."
Now, we may summarize the general principles which
regulate the use of electric currents as follows:
1. They may exert, under certain circumstances, a stimu-
lating or irritating effect. This is, perhaps, the basis of the
most varied applications of electricity to disease.
2. They may exert, when properly applied, a sedative
action on nerves or nerve-centers.
3. They may be made to exert a catalytic action upon
neoplasms, enlarged glands, etc.
4. They are capable of causing electrolysis. This action
is one which has lately come into prominence.
5. They create heat under certain conditions. The
galvano-cautery is to-day assuming a very prominent place
in some of the departments of surgery.
Let us now discuss each of these special actions sepa-
rately, noting the general points of interest pertaining to
each which will aid us in properly treating our patients.
Electrolysis and the galvano-cautery have been treated of in
previous lectures.
Stimulating or Irritating Effect of Electricity. —
This is indicated in many diseased conditions. Among
these the following may be prominently meutioned :
Some of the various forms of cerebral and spinal dis-
eases.
Depressed irritability of some special nerve-trunks.
Abnormal resistance to conduction of electric currents,
exhibited by the motor or sensory nerve-filaments of some
part.
As a counter-irritant to some pathological conditions.
Trophic disturbances of special regions (skin, nails, hair,
etc.).
Vaso-motor depression.
Atrophic changes in muscles.
As a means of indirectly affecting the nerve-centers
through the sensory nerves, thus influencing respiration, cir-
culation, phonation, vaso-motor paths, peripheral organs,
the muscles, etc.
The methods of application which are best adapted to
accomplish irritating or stimulating effects are differently
stated by authors. Personally, I do not confine myself ex-
clusively to faradaism or galvanism.
The faradaic current is more commonly employed for
this purpose than the galvanic. The electrodes should be
selected, as to their size and shape, in accordance w ith the
parts to be acted upon ',„they should be well moistened with
salt water, and kept closely in contact with the skin. The
wire-brush is the best electrode to stimulate the nerves or
other tissues of the skin. It should be used dry. 1 prefer
the secondary faradaic current to that of the primary coil
for stimulating effects.
If galvanism is employed as a stimulant, Remak's plan,
of moving the well-moistened cathode rapidly over the
nerve-trunk or muscle to be stimulated, with a current suffi-
ciently strong to cause strong wave-like contractions, is a
good one. Another method, termed by this author " ter-
minal labile stimulation," consists in stroking the tendinous
86
RANNEY: LECTURES ON ELECTRICITY IN MEDICINE.
[N. Y. Med. Jock.,
end of a muscle with the cathode so as to affect the entire
length of the muscle. In both of these methods the anode
is kept stationary upon some indifferent or neutral point —
the center of the sternum by preference, or the nape of the
neck.
One of the most vigorous methods of stimulation con-
sists in rapidly changing the polarity by means of a com-
mutator, when the galvanic battery is employed.
The Combined Current. — Another method which I em-
ploy (not generally mentioned in text-books) consists in
connecting a galvanic battery, by means of a rheophore, with
a faradaic instrument, thus bringing both a constant and in-
duced current to bear upon the tissues at once. The rheo-
phore which connects the batteries joins the positive bind-
ing-post of the galvanic instrument with the secondary coil
of the faradaic ; the two rheophores connected with the elec-
trodes run from the negative binding-post of the galvanic
and from the secondary coil of the faradaic instrument. The
two instruments (faradaic and galvanic) are thrown into
action simultaneously, and the strength of the current em-
ployed is graduated by the number of cells used in the gal-
vanic battery and by the extent of the overlap of the sec-
ondary coil of the faradaic instrument. I have obtained
some remarkable results by the stimulation thus produced
in various forms of trophic disturbances of the skin and
muscles.
The stimulation of nerve-fibers (when obstacles exist to
their conduction) should be performed peripherally from
the site of the lesion in sensory nerves, and as centrally as
possible in motor nerves (Erb). Degenerated and atrophied
nerves and muscles require a direct effect of the currents
employed. For these reasons, the site of stimulating elec-
trical applications depends upon the situation and character
of the lesion and the object to be attained.
Modifying Effects of Electric Currents. — The irri-
tability of nerves and muscles may be influenced by electric
currents.
In certain diseased conditions we may expect a favorable
result from such an action. Thus, for example, in some
types of paralysis, in anaesthesia, in certain vaso-motor dis-
turbances, and in depressed states of cerebral and spinal
activity, the irritability of nerves or of muscular fibers is
diminished ; hence we resort to the so-called " catelectro-
tonic action " of electricity as a means of stimulating and
restoring the normal irritability of the tissues affected.
It is now generally accepted as proved that feeble faradaic
currents will accomplish this end. Galvanic currents, when
applied for this purpose, give more positive results, however,
than faradaic.
In order to increase irritability by galvanism, the nega-
tive electrode should be applied in a stabile manner (i. e.,
without being moved) to the part upon which this effect
is to be produced ; and the strength and duration of the
current should be steadily increased. When the muscles
or motor nerves have been exhausted by over-exertion, ex-
cessive fatigue, etc., this action (termed by Heidenhain
the " refreshing action " of galvanism) is particularly in-
dicated.
Those conditions in which the normal irritability of
nerves or muscles is intensified demand the so-called " ane-
lectrotonic action " of electricity. These conditions com-
prise all irritative states of the sensory, motor, and vaso-
motor tracts within or without the brain and spinal cord ;
hence we employ this action in neuralgias, spasmodic affec-
tions, hypenesthesia of any of the cerebro-spinal nerves,
headache, excitation of any of the special senses, cerebral
and spinal irritation, etc.
In order to decrease the irritability of nerves or muscles,
we may employ very powerful faradaic currents. We may
also begin by employing a feeble faradaic current and grad-
ually increasing its strength to the highest point of endur-
ance ; then maintaining it at this point for some time ; and
subsequently reducing it gradually to the feeblest current
perceptible to the patient. This method is known as the
" increasing induction method." Electrodes well-moistened
and of large size should be employed and kept immovable
upon the same points during the application. It is often
advisable to repeat this procedure several times at one sit-
ting (Erb).
When the galvanic current is employed for the purpose
of decreasing irritability, the positive pole is made fast at
the point to be influenced. The current is increased in
strength and maintained at its maximum for some time, after
which it should be decreased gradually until it can not be
perceived by the patient. The gradual decrease of the cur-
rent-strength prevents the marked temporary increase of
irritability which is liable to follow this method when this
step is omitted.
Static electricity exerts in many cases an immediate bene-
ficial effect upon neuralgic pains (especially upon sciatica)
and upon the various spasmodic affections, as, for example,
chorea, paralysis agitans, tremor, contracture, etc. These
effects are obtained, in some cases, when galvanism and
faradaism have proved of no benefit. I should never regard
a case as incapable of benefit by electric treatment until
static electricity, in the form of insulation, the electric wind,
or the spark, had been thoroughly tested. I have had bet-
ter results with this form of current in tremor than with
galvanism or faradaism.
Some forms of pain (as, for example, the pains of ataxia,
sciatica, trigeminal neuralgia, muscular rheumatism, etc.)
are oftentimes relieved by a few applications of static elec-
tricity. My experience with this agent has convinced me
that its effects are often satisfactory in cases where pain is a
prominent symptom, when galvanism has been tried with-
out benefit. I have found that insulation and the abstrac-
tion of heavy sparks from the seat of pain give the best
results.
Catalytic Action of Electrical Currents. — Under
this heading we include (1) an increase of absorption pro-
duced by dilatation of the capillary blood-vessels and lym-
phatics; (2) an increased capability of tissues for imbibi-
tion of fluids, through an increase of osmotic processes ;
(3) changes in the disassimilation and nutrition of nerves,
on account of their stimulation or "refreshing effects; (4)
changes in the molecular arrangement of tissues, caused by
electrolytic processes; and (5) the results of the transporta-
tion of fluids from one pole to the other (Remak and Erb).
July 25, 1885.]
INOALS: LEU COP LA EI A
BUCGALIS ET LI NQ UAL IS.
87
Remak has shown that muscles become congested and
greatly swollen when subjected to galvanism. They are
rendered tense, and (according to this observer) absorb
water more freely than muscle which has not been galva-
nized.
Changes of a marked character may be induced in the
skin by galvanism. These have been studied by Erb, Re-
mak, Bollinger, and others.
The vaso-motor nerves may be influenced by electrical
currents. This is shown by many of the later investiga-
tions— prominently those of Loweufeld, which demonstrate
that contraction and dilatation of the vessels of the brain
result, respectively, from antero-postcrior and transverse cur-
rents through the head from a galvanic battery.
Although we are, as yet, unable to speak with positive-
ness regarding the certainty of the catalytic effects of elec-
trical currents, or to map out the forms of disease which
are to be regarded as specially indicating these catalytic
effects, still it may be said that the following states have
been successfully treated by electrical currents, and that the
cures are probably to be attributed to a catalytic action :
(1) Inflammatory affections of the nervous system, includ-
ing sclerosis, myelitis, neuritis, etc. ; (2) arthritis and
chronic exudations into joints; (3) glandular enlargements ;
(4) hard cicatrices, periosteal swellings, and fibrous adhe-
sions ; (5) contusions, sprains, extravasations of blood, and
other results of traumatisms.
The galvanic current is the one that is generally em-
ployed when catalytic effects are desired. In diseased con-
ditions of the brain, spinal cord, or any of the deeply
seated organs, the faradaic currents are not usually produc-
tive of benefit.
The " stabile method " of application of the galvanic
current is preferable, to my mind, when catalytic action is
to be attained. The strength of the current should be suf-
ficient to easily overcome the resistance offered, and the
duration should be sufficiently prolonged to accomplish
changes in the tissues subjected to its influence. One pole
is placed, as a rule, at an indifferent point (the sternum by
preference), and the other over the tissue diseased. Some-
times, as in the case of the brain, for example, the poles are
placed upon either side of the diseased part. Although
there are exceptions to the rule, it is well to use the anode
or positive pole over the diseased part when pain is pres-
ent, when symptoms of active irritation exist, or when the
morbid processes are very active. The cathode or negative
pole is best adapted to influence chronic morbid processes,
such as sclerosis, indurations, etc. Erb recommends that
the polarity of the current be changed several times in
either case ; he doubts the infallibility of the rule given,
although it is theoretically sound. Chvostek urges the use
of short and moderate currents for a few minutes (three to
ten) when catalytic action is desired. In this way, he
believes, the vaso-motor and trophic nerves are more im-
pressed than by any other method.
Respecting the catalytic action of faradaic currents, a
difference of opinion exists between authors of note. One
thing is certain — viz., that strong currents are required, and
that the currents must be passed directly through the dis-
eased part to accomplish marked results. Glandular tumors
have been resolved by this method with great rapidity in
some recorded instances.
( To be continued.)
(Jprirjinal Communications.
LEUCOPLAKIA BUCCALIS ET LINGUALIS,
OR ICHTHYOSIS LINGUAE;
SUCCESSFUL TREATMENT WITH THE GALVANO-CAUTERY*
By E. FLETCHER INGALS, M. D.,
PROFESSOR OP LARYNGOLOGY IN THE RUSH MEDICAL COLLEGE, AND OF DIS-
EASES OF THE THROAT AND CHEST IN THE WOMAN'S MEDICAL COLLEGE,
CHICAGO.
During the past year it has been my good fortune to
cure a case of the rare and intractable disease which forms
the subject of this paper.
This disease has been recognized but a short time, and
very little can be found upon the subject in general medical
literature, but, by a thorough search in the library of the
Surgeon-General's Office in Washington, I found about fifty
papers, mostly reports of cases, which, with the single ex-
ception of one by Bazin, which I take second-hand, seem to
embrace all that has been written concerning the disease.
The literature is involved in what at first seemed inex-
tricable confusion, for the reason that several different affec-
tions have been confounded and described under the same
name. Thus, " smokers' patches," the peculiar condition of
the mucous membrane of the mouth found in old glass-
blowers, termed by Guinaud f " professional patches," psori-
asis lingua?, and various manifestations of syphilis, have
been considered by different authors as true leucoplakia, or
as one of its phases.
The term leucoplakia, which, of the names proposed for
this affection, seems open to least objection, was suggested
by Professor Schwimmer,J who gives a lengthy and exhaust-
ive description of the disease. Ullmann * employed the
term tylosis, which is strongly advocated by W. Fairlie
Clarke. I The affection was first brought prominently before
the profession by J. W. Hulke,A under the title ichthyosis
linguae, a name which has been (mite generally accepted
save by Debove () and some other French writers, who have
described it, together with other affections, as a manifesta-
tion of psoriasis.
Definition. — Leucoplakia buccalis is a chronic affection
of the buccal mucous membrane, characterized by thickening
of the epithelium, and the formation of white, opaline, ele-
vated patches, whicfi usually become fissured ami painful,
and, after continuing for a long time, are likely to terminate
in epithelioma.
* Read before the American Laryngological Association, June '24,
1885.
f "Syphilis des reniers," "Lyon nied.," xnxv, 1880.
\ " Vierteljahresschrift fur Dermatologie," iv, 1877.
* "Aer/.tlich. Intelligenzblatt," Munich, v, 1858.
|| " British Med. Jour.," 1874, vol. i.
A "Med. Times and Gazette," London, 18f>f>, vol. i.
v Paris thesis, 1873.
88
1NGALS: LEUCOl'LAKIA BUCCALIS ET LINGUALIS.
[N. Y. Med. Jock.,
History. — The first mention that I can find of ichthyosis
lingua? is in a paper under the title of "Maladies de la
peau," 1822, by Alibert, who records a case, reported in
some of the journals, of a young woman in Naples who had
extensive ichthyosis of the skin, which finally involved the
tongue and lips. In 1837 Samuel Plumbe* described a
case of enlargement of the papilla; of the tongue which lie
regarded as precisely similar in its nature to local ichthyo-
sis of the skin. In 1858 Ullmann f described a case of leu-
coplakia under the name of tylosis. In the same year J. J.
Buzenet J reported two cases of undoubted leukoplakia, and,
in 1861, J. W. Hulke* recorded a case under the title of
" Wart and Corn of the Mucous Membrane of the Tongue."
The following year Sir William Fcrgusson || presented a
somewhat similar case in a clinic at the King's College Hos-
pital, and in the same year, in the report of a clinic by Dr.
Andrew Clark,A we find a case described under the name of
aphtha figurata, which is supposed by some to have been true
leucoplakia, but which seems to have been psoriasis of the
tongue. The same year J. Moore Neligan v notes a case of
true leucoplakia which finally terminated in epithelioma.
February 28, L865, .1. W. Hulke, J of London, presented what
is generally credited as the first paper on the subject to the
Royal Medical and Chirurgical Society. Subsequently brief
articles appeared on the subject by S. James A. Salter,^
1866; Bazin,J 1868; M. Lailler,** 1869.; Sir James Paget,ff
1870; C. Saison,JJ 1871 ; and W. Fairlie Clarke** 1872.
Finally, in 1873, Charles Mauriac |||| published an exhaustive
article on the subject under the title of " I >u psoriasis de la
(angue et de la muqueuse buccale." Since Mauriac's article
numerous papers have appeared, the most important of
which are by M. G. Debove,AA 1873 ; Henry Morris,^ 1874 ;
W. Fairlie Clarke,J J the same year ; Robert F. Weir,|J 1875 ;
Professor Ernst Schwimmer, JJ 1877 and 1881; and E.
Vidal,*** 1883.
The disease is very rare, but its frequency can not
be accurately determined, on account of the diversity of
opinion which has been entertained by different writers
with reference to its aetiology and diagnosis — a diversity
which has caused many cases to be placed in this class
which do not properly belong in it. Professor Schwimmer
saw only twenty examples out of five thousand cases of
* "Diseases of the Skin," Philadelphia, 183V.
\ Loc. cit. \ Paris thesis, 1858.
* "Med. Times and Gazette," London, 1861, vol. ii.
I "Lancet," London, 1862.
A "Med. Times and Gazette," London, 1862, vol. ii.
0 " Notes of an Unusual Abnormal Condition of the Mucous Mem-
brane of the Tongue and Cheeks considered in Connection with Life
Assurance," 1862.
% Lor. cit. % "Papillary Tumors of the Gums," 1866.
| Paris thesis, 1873.
** " Diet, encycl. des sci. med.," Paris, 1 869.
ft "Case of Cancer following Ichthyosis of the Tongue," 1870.
}4 Paris thesis, xlvi, 1871. ** "Lancet," London, 1872, vol. i.
|| || "L'Union medicale," xvi, 1873. ^ Paris thesis, 1873.
v<) " British Med. Jour.," 1874, vol. vi. XX Lf>r- <'''•
%% "N. Y. Med. Jour.," vol. xxi, 1875.
\\Loc. cit., and " Transactions of the International Med. Cong.,"
London, vol. iii, 1881.
*** "L'Union m6d.," xxxv, 1883.
diseases of the skin and syphilis, and many others have not
seen so large a proportion as this ; but doubtless many cases
are not recognized, and pass for constitutional syphilis.
Most of the cases have been reported from Germany,
France, and England, but some have been recorded in this
country. So far the records show that the disease seldom
affects any excepting males over forty years of age, though
it has been observed as early as the thirty-second year, and
a very few examples have been seen in women.
Anatomical Characters. — The patches are generally
found on the dorsum of the tongue or the inner surface of
the cheek and lips, but seldom, if ever, on the lower surface
of the tongue or behind the anterior pillars of the fauces, and
they are limited to the buccal cavity.
They may be seen in one or more small, irregular, or
oval patches, or these may have become confluent. A con-
siderable portion of the tongue alone may be involved, or
the dorsum of the tongue, the buccal mucosa, and the sur-
face of the jaw may one or all be affected.
The first appearance of the white patch is preceded by
hyperemia, and in the early stages a hypenemic areola is
found about its borders. Afterward the patch itself is more or
less thickened, sometimes to the extent of six or eight mm.,
and the epithelium, which has become hard and dry, may be
easily removed, or in spots it may have been spontaneou-l v
exfoliated, leaving the appearance of an ulcer.
The surface of the patch is marked by numerous fine
lines or furrows, wbich intersect each other, dividing it into
small polygonal spaces. Some of these may extend as deep
fissures down through the thickened epithelium, and in-
volve the mucosa in painful ulceration. In cases of lon<>-
standing the papillae may be much enlarged, giving the sur-
face a warty appearance.
Under the microscope the epithelium is found greatly
thickened, tbe papilla; enlarged and flattened, the blood-
vessels dilated, with an accumulation of leucocytes about
their walls. The superficial layer of the mucous corium is
infiltrated with embryonic cells, and the deep layer is in-
volved in vascular alterations.
According to Hulke,* there is hypertrophy of the epi-
thelial and papillary layer of the mucous membrane, similar
to the condition of the skin termed ichthyosis.
In 1874, W. Fairlie Clarke f spoke of the disease as a
chronic inflammation and papillary growth, but in later
writings he does not strictly adhere to these views.
Mauriac J says "it is certain that it is a chronic inflam-
mation of the parts involved."
In the first stage of the affection, hypera?mia of the
deeper layers of the epithelium exists, which is soon fol-
lowed by exudation, and this consolidating causes indura-
tion.
The epithelial cells are increased and the papilla? en-
larged, but later, when the affection merges into epithelioma,
there is, according to Clarke,* an enormous increase of the
rete mucosum at the expense of the papilla?, which are then
reduced to mere threads.
Causation. — Excessive tobacco-smoking is ranked as one
of the most frequent causes of the disease, but it is barely
* Loc. cit. f Loc. cit. \ Loc. cit. * Loc. cit.
July 25, 1885.]
INQALS : LEU COPLAKIA BUGGALIS ET LINOUALIS.
89
possible that prolonged irritation of any character muy
have a similar effect on those predisposed to it.
Thus, Mauriac * and Vidal f mention highly spiced foods
and alcoholic stimulants as irritants which must be avoided.
SchwimmerJ calls the affection idiopathic, but both
he and Mauriac think there must be some peculiar pre-
disposition toward it in order that it may be developed.
Bazin,* who has seen the affection in several members
of the same family, believes that it is often, if not usuallv,
the result of constitutional syphilis.
Mauriac believes that all psoriasis of the mouth and
tongue supervening in syphilis is not necessarily syphilitic,
and may not take part in the syphilitic disease.
Debove, Bazin, and Mauriac attribute it frequently to
the arthritic or dartrous diathesis. Thus it will be seen
that the cause of the affection is not definitely known,
though it is commonly believed to be induced by smoking
in most instances. It must not be forgotten, however, that
several cases have been recorded in persons not addicted to
the use of tobacco. In those who use tobacco to excess it
is not necessarily the irritant effects of the smoke or heat
that cause the disease, but, as in the case here appended, the
noxious influence of the tobacco itself.
Clinical History. — It is also difficult to determine exact-
ly the duration of the disease, for it has generally been dis-
covered accidentally ; but usually it will be found to have
existed for months or years when the patient first presents
himself. This is due to the fact that at first the affection
causes no inconvenience. Usually the small patch first ob-
served gradually increases in size until at length stiffness of
the part occurs or painful fissures form, which cause the pa-
tient to seek advice.
In some cases the epithelial cells gradually pile up until
a thick, horny mass is formed, which may then be thrown off
spontaneously or pared off by the patient as he would cut
off a corn or wart. After a time, varying from a few months
to many years, the formation of fissures and ulcers causes
pain, and finally, in a large percentage of cases, epithelioma
results and runs its usual course. Sometimes the affection
will remain stationary for months, or, under the influence of
some irritant, it may rapidly progress, but may again become
dormant if the irritant is removed. Occasionally unchang-
ing erythematous patches remain in the surrounding mucous
membrane for years.
In the cases associated with syphilis and in those that
have developed into epithelioma the parts become greatly
swollen, and deep, fungous ulcers occur which may erode
vessels and cause serious haemorrhage. In these same cases
the lymphatic glands are involved, but this does not occur in
the earlier stages of idiopathic leucoplakia.
Often the first symptom noticed by the patient is simply
an uneasy sensation ; but this may not appear until the dis-
ease has existed for years. In other cases the mucous mem-
brane early becomes sensitive, so that spices, hot food or
drinks, alcoholics, tobacco, etc., cause more or less pain.
When deep fissures occur, the pain may become intense and
almost constant, though in some cases it is present only at
intervals. There are no constitutional symptoms until epi-
thelioma is developed. Late in the disease, speaking, mas-
tication, and swallowing sometimes become difficult, espe-
cially when epithelioma occurs. In such cases there is also
profuse and very troublesome salivation, which continues
both night and day.
Upon examining the mouth in the early stages, several
more or less oval red or white patches are usually found
which are apt to be mistaken for secondary syphilis. These
in time become bluish, and finally, with increase in their epi-
thelial covering, grayish or of a milky white color — like mu-
cous membrane touched with nitrate of silver. These spots
may remain distinct for a long time, but with the progress
of the disease they become confluent, and at length form
large, irregular patches. At first the surface of the patch is
usually smooth, marked only by fine intersecting fissures,
and is but slightly elevated above the surrounding mucous
membrane. At this time the papilbe are often prominent
and large, but, as the epithelial cells accumulate, they
atrophy and are buried out of sight, and the surface may
become raised several millimetres above the healthy mu-
cous membrane. In some instances we find that a portion
of the horny mass has been thrown off, and has left a
central depression which may be ulcerated. These latter
changes take place only in those cases which have been ex-
posed to great irritation or which are approaching the stage
of epithelioma. About the younger and growing patches
we find an erythematous border, but this finally disappears.
In cases associated with syphilis, cicatrices and nodosities
or deep fissures of the tongue are usually found, and, in
those which have passed into epithelioma, induration and
thickening of the subjacent tissues, with deep, unhealthy
ulcers, are likely to be present.
Diagnosis. — Leucoplakia is liable to be mistaken for
what Guinaud * has termed the " professional patches,"
found in glass-blowers, for " smokers' patches," mercurial
patches, psoriasis linguae, syphilitic patches, and epithe-
lioma unconnected with leucoplakia. The "professional
patches" occur only in old glass-blowers, particularly in
bottle-makers, and are found symmetrically upon both sides
of the mouth, on the lateral surface of the jaw, and around
Stenson's duct. " Smokers' patches " are more irregular
in seat than those of leucoplakia, and are commonly locat-
ed near the commissures of the lips, but not upon the dor-
sum of the tongue or inner side of the cheek. Again, the
epithelium covering their surfaces is thin and closely ad-
herent, so that it can not be removed, as in the disease
under discussion. Mercurial patches are not so thick as
those of Jeucoplakia, are never quite white, and are found
on all parts of the tongue, but particularly where it is
pressed against the teeth. According to W. Fairlie Clarke, f
psoriasis is an affection in which circumscribed patches of
epithelium assume a white, opaque appearance, which, after
a day or two, are thrown off, when the epithelium is speed-
ily restored; but soon other patches appear and go through
the same course, until, after a time, the whole surface of
the tongue becomes denuded and of a uniform red color.
* Loc. cit. f Loc. cit. \ Loc. tit. * Loc. tit.
* Jjoc cit.
f Loc. cit.
90
INGALS: LEUCOPLAKIA BUCCALIS ET LING HALTS. [N. Y. Med Joub.,
with crescentic markings or depressions, which, it will be
observed, is rery unlike the course of leucoplakia. Syphi-
litic patches are not so white as those of leucoplakia ; they
are usually round or oval, and more regular in form, and
they seldom occur on the cheek, but are found principally
on the tip or margins of the tongue, and often on its lower
surface, which is never invaded by leucoplakia. Syphilitic
patches do not become so thick as those of leucoplakia,
and in syphilis the lymphatic glands are soon involved,
which is not the case in the latter unless it has become can-
cerous. The pain is more severe in leucoplakia than in the
syphilitic disease, and anti-syphilitic treatment causes no
improvement, but may aggravate the affection. When
syphilis and leucoplakia co-exist, the diagnosis is difficult,
and sometimes can only be cleared up by specific treatment.
Cancer arising without previous leucoplakia is distinguished
from the latter by its history. In cancer, the induration of
tissues and the final ulceration are not preceded by the
chronic white patch, and are attended by more constant
pain, with profuse salivation and a very offensive odor.
Prognosis. — The duration of the disease is uncertain
One authority mentions two cases in which cancer super-
vened in less than six months. Sir James Paget * mentions
one case which terminated in cancer at the end of eighteen
months, several of Mauriac's \ were of eleven to thirteen
years1 duration, while of the two cases seen by Hulke, J
which terminated in this way, one had existed twenty
years. Others have mentioned cases of thirty to fortv-five
years' duration. Debove* and Bazin,|| who make no clear
distinction between leucoplakia and syphilis, and Kaposi,A
who speaks of leucoplakia as a universal product of syphilis,
very naturally believe that the affection is frequent, that it
does not terminate in cancer so often as we should suppose
from the writings of others, and that it is very amenable to
treatment. Schwimmer Q says that the diseaFe is frequently
transformed into malignant formations and ends fatally,
and the general belief is that it is very likely to end in epi-
thelioma. Yidal J believes that one half the cases terminate
in this way. On this point Mauriac| says that "transfor-
mation into epithelioma has often been noted, therefore it
is important to cure the superficial affection, or it may pass
into a deep, destructive, mortal disease."
The same author thinks that there are three varieties of
leucoplakia (or, as he terms it, psoriasis lingua;). One,
which he says is curable (due to syphilis), we do not
think belongs to this class of diseases. The others he
considers incurable. The variety which he attributes to
the arthritic or dartrous diathesis he terms innocuous,
while the third variety — the epitheliomatous — is incurable
and malignant.
Among the indications that leucoplakia is passing into
epithelioma are : non-inflammatory enlargement of the lym-
phatic glands, with exfoliation of the thicker portion of
the patch, the formation of an ulcer, the supervention of
sharp pain, salivation, and at length induration of the sub-
jacent tissues. Finally, great swelling in the region of the
* Loc. cit. \ Loc. cit. \ Loc. cit. * Loc. cit. || Loc. cit.
A "Syphilis der Haut," Wien, 1876, vol. iii.
Q Loc. cit. % Loc. cit. $ Loc. cit.
jaw is likely to occur, and death takes place from exhaus-
tion.
Treatment. — In cases of leucoplakia all sources of irrita-
tion, particularly those resulting from the use of tobacco
and alcoholic stimulants, should be at once removed, and if
the digestive organs are deranged, as is frequently the case,
they should receive proper attention. Aside from these
measures, most authorities believe treatment of little or no
avail. Schwimmer* says that local* treatment is not ra-
tional ; that alkaline washes and the waters of Vichy and St.
Christan, and other alkaline waters, though highly recom-
mended by Bazin f and other French writers, are not satis-
factory in their effects ; and that, even if improvement does
occur under their use, it is not likely to be enduring.
Debove \ and Bazin state that many cases of buccal psoria-
sis may be cured, but their favorable results may be due to
the fact that they included many syphilitic cases in this class.
By an examination of Debove's recorded cases, I find that,
exclusive of the syphilitics, none of the patients seem to have
been entirely cured, though many were treated by both Bazin
and Debove, and a number are reported as " something
better " after several months of treatment. Mauriac,* who
believes that there are three varieties of leucoplakia — viz. :
1, the dartrous and arthritic; 2, the syphilitic; 3, the epi-
theliomatous— recommends arsenic and alkalies for the first,
mercury and iodides for the second, and surgical measures
for the third ; however, he urges great prudence in using
any of these measures, and states that the internal remedies
have been found almost useless, and that mercury and the
iodides are dangerous in the absence of syphilis.
For local application, the caustics which have commonly
been employed are nitrate of silver, chloride of zinc, tinc-
ture of iodine, and acid nitrate of mercury ; but none of
them seem to do any good excepting in syphilitic cases,
which I do not include under the term leucoplakia. Sooth-
ing applications seem to have been most beneficial, but they
give only temporary relief.
E. Vidal || says that " mercury and iodide of potassium
aggravate the disease the more advanced it is," and that in
the papillomatous state they precipitate epithelioma. When
the affection has passed into epithelioma nothing can be of
much benefit excepting thorough excision, but even this
has not often been followed by happy results.
Henry Morris A advises that, after other measures have
been fairly tried, if the epithelium is constantly thrown off,
leaving abrasions or ulcerations which are painful, the
tongue should be excised without delay. He states that
" the prospect of curing, or even much improving, ichthyosis
by treatment is most unfavorable."
S. James A. Salter Q reported a case, which seemed to
have been leucoplakia, which was cured by extirpation and
cauterization of the wound with the actual cautery. In the
case which I report it will be observed that internal reme-
dies did no good, and that local applications of tincture of
iodine, nitrate of silver, and the acid nitrate of mercury
greatly increased the patient's sufferings, and would doubt-
less have aggravated the disease had they been persisted in ;
* Loc. cit. f Loc. cit. J Loc. cit. * Loc. cit.
I Loc. cit. A Loc. cit. v Loc. cit.
July 25, 1885.1
IN GALS: LEVCOPLAKIA BUCCALIS ET LINO UA LIS.
91
but, as soon as the actual (galvanic) cautery was employed,
relief from all pain was obtained, and by a persistent, care-
ful use of it the disease was eradicated.
In considering this favorable result, of course we must
not overlook the reported tendency of the disease to recur ;
but the fact remains that the belief in this tendency is based
on a study of cases in the majority of which the diseased
patch was never entirely removed. In my case the mucous
membrane is perfectly healthy after a lapse of four months;
therefore I believe the treatment adopted for it will prove
curative in many cases if applied before epithelioma has
developed.
From a study of the literature of this subject, and from
my own small experience, I arrive at the following conclu-
sions :
1. Leucoplakia buccalis is an idiopathic disease, distinct
from psoriasis, " smokers' patches," and syphilis. It is
largely confined to men past middle life, but it occasionally
occurs in women.
2. The disease is so commonly found in inveterate
smokers that the abuse of tobacco may fairly be considered
as au exciting cause, though cases occur where tobacco has
never been used.
3. The affection is chronic and, finally, in a majority of
cases, terminates in epithelioma.
4. Internal treatment and the local application of seda-
tive, stimulant, or caustic drugs are, in nearly all cases, either
useless or injurious, and the latter are sometimes disastrous
by hastening the development of epithelioma.
5. The actual cautery or the galvano-cautery will prob-
ably enable us to cure many cases if they are treated suffi-
ciently early, provided it is applied to only a small spot at
each sitting, and carefully, so as not to destroy the healthy
tissues beneath the changed epithelium.
A Typical Case. — L. 0., aged forty-three, printer, came to
me in September, 1884, complaining of a sharp pain in the left
side of the mouth, particularly when eating. This, he said, began
two years before, when he had a tooth drawn. Two months
later he first noticed a small white patch on the buccal raucous
membrane. Upon examining the mouth, I found a large, irregu-
lar, milk-white patch, extending from the border of the gums
down through . the gingivo-buccal groove, upward along the
left cheek, and from the first bicuspid tooth, in front, to the
last molar, behind. Altogether this was as large as a silver
dollar; its surface was marked by fine intersecting lines, which
divided it into numerous polygonal spaces.
At the center of the patch, on the buccal surface, was a de-
pression about 3 mm. in depth and 1 era. in diameter, sur-
rounded by elevated, hard margins, which gradually became
thinner toward the edge of the patch. This margin was deeply
fissured in two or three places. About half an inch in front of
the anterior portion of this patch, on the UDder lip, was a small,
white, warty growth, about 4 mm. in height by 3 mm. in
diameter.
A critical investigation of the case failed to discover any his-
tory or signs of syphilis or hereditary disease. The patient
chewed tobacco to excess and had smoked occasionally. He
stated that previous to the removal of the tooth, and until the
pain became troublesome, he had been accustomed to carry his
quid of tobacco in the left side of the mouth, at the location of
the patch. His general health was perfect, and ho had never
suffered from rheumatism or eruptive diseases, and did not use
alcoholic stimulants. During the first few months of the affec-
tion paiu came on about once in two weeks and would last sev-
eral hours, but the attacks gradually became more frequent, un-
til seven or eight weeks before I saw him, during which time
the pain had been constant and often severe. The patch had
been cauterized occasionally with nitrate of silver, but was never
benefited.
When I first saw the case, suspecting that it might be syphi-
litic, I ordered iodide of potassium in large doses and directed
that tobacco be discontinued. I cauterized the patch with tinc-
ture of iodine, but the application caused such severe and pro-
tracted smarting that I began at once to be doubtful about the
character of the disease. Three days later I applied the solid
nitrate of silver to a small portion of the patch, with similar re-
sults, and four days later the acid nitrate of mercury. This last
application caused intense pain that lasted about seven hours,
which, he said, drove him nearly crazy. I was now convinced
that the disease was not syphilitic, and had the patient see Pro-
fessor Hyde, who pronounced it leucoplakia. I next cauterized
the central depressed portion of the patch with the galvano-
cautery, which caused momentary smarting, but perfectly re-
lieved the severe pains from which he had suffered for weeks,
and they never returned. Two days later I destroyed the small,
wart-like projection in front of the large patch, and subsequent-
ly, about every fifth or sixth day, I cauterized a small spot,
nearly a centimetre in diameter, at the edge of the patch.
These cauterizations were so superficial that only the epitheli-
um was destroyed, the membrane beneath being but slightly
burned ; indeed, so light were they that a few times I was
obliged to again cauterize the same spot before all the epithe-
lium was destroyed. I found that as these* cauterized places
healed the mucous membrane appeared natural, and finally,
after about thirty applications of the cautery, the entire surface
presented the appearance of healthy mucous membrane, show-
ing only two or three small cicatrices, where the cauterizations
had been unusually deep. The iodide of potassium, which did
no good, was discontinued soon after I began the use of the gal-
vano-cautery. Now, at the end of four months after the last
cauterization, the mucous membrane remains perfectly healthy.
Bihliography.
Alibert. "Maladies de la peau," Paris, 1822.
Bazix. " Psoriasis buccal," Paris thesis, 1873.
Buzenet, J. J. A. " Chancre de la bouche," Paris thesis,
225, 1858.
Church, William. "Report of a Case of Ichthyosis, with
Congenital Malformation of the Aorta," 1865.
Clark, Andrew. "Aphtha Figurata ; Clinical Remarks on
its Pathology and Treatment," " Medical Times and Gazette,''
vol. i, 1862.
Clarke, W. Fairlie. " Case of Ichthyosis Lingua?," " Lan-
cet," vol. i, 1872. See also "British Medical Journal,-' vol. i,
1874; "Practitioner," London, vol. xiii, 1874; "Lancet,"
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Chir. Trans.," 1874, vol. ii. "Exfoliation of the Tongue,"
1882.
Debove, G. M. " Psoriasis buccal," Paris thesis, 1873. " I)u
psoriasis buccal," "Archives gen. de med.," xxiii, 1874.
Devergie. " L'Union mod.," xxii, 1876.
Febgtjssoit, Sir William. " Clinical Remarks on a Peculiar
Form of Disease of the Jaw in an Aged Patient," "Lancet,"
1862, vol. ii.
Fox, Tilbury. "So-called Ichthyosis Lingua? and its Re-
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vol. i.
92
WES TBROOK : ANTIPYRINE IN SUNSTROKE.
[N. Y. Med. Jour.'
Fournier, Alfred. " Des glossites terti:iires>," Clinical
Lectures, " La France med.," xxiii, 1876.
Fredet. "Bull, et mem. <le la soc. de chir. de Paris," vol.
ii, 1876.
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"Revue med. de la Suisse romande," 1881, vol. i.
Goodhart, James F. " On Cancer, as illustrated in Ichthy-
osis of the Tongue and Allied Diseases resulting from Prolonged
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Guinaud. " Syphilis des reniers." " Lyon med.," xxxv,
1880.
Httlke, J. W. " Wart and Corn of the Mucous Membrane
of the Tongue," "Med. Times and Gazette," London, 1861,
vol. ii. " Ichthyosis of the Tongue," from " Med. Times and
Gazette," 1865, vol. i, London. See " Proceedings of the Royal
Med. and Chir. Soc," 1865, vol. v, London.
Hugonneau. Report of a case of glossitis, ending in epi-
thelioma. Paris thesis, 431, 1876.
Kaposi. "Syphilis der llaut," Wien, 1875, vol. iii.
Krueg, Julius. "Leucoplakia linguae bei einem Geistes-
kranken mit Vergiftungsideen," " Wien. med. Woch.," 1878.
Leloir. "Progres mod.," Dec. 15, 1883.
Lailler, M. Art. "Bouche," "Diet, encycl. des sci. med.,"
vol. x, Paris, 1869.
Mauriac, Charles. " Du psoriasis de la langue et de la
muqueuse buccale," " L'Union medicale," xvi, 1873. Definition
based upon anatomo-pathological constituents of bucco-lingual
psoriasis, Ibid., xvii, 1874.
Morris, Henry. "Remarks on Ichthyosis Linguae followed
by Epithelioma Linguae," with notes of three cases, " British
Med. Journal," Feb. 21, 1874. See "British Med. Journal,"
March, 1874, London. " Remarks on Epithelioma and Ich-
thyosis of the Tongue, based on Records of Seventy-five Cases,"
"Lancet," 1882.
Merklen, P. t " Psoriasis buccal de Bazin," " Annales de
derm, et de syph.," vol. iv, 1883.
Nedophil, M. " Ueber die Psoriasis der Zungen- und Mund-
schleimhaut und deren Verhiiltniss zum Carcinom," Langen-
beck's "Arcbiv," Berlin, vol. xx, 1877.
Neligan, J. Moore. " Notes of an Unusual Abnormal Con-
dition of the Mucous Membrane of the Tongue and Cheeks con-
sidered in Connection with Life Assurance," 1862.
Paget, Sir James. " Case of Cancer following Ichthyosis of
the Tongue," 1870.
Plumbe, Samuel. "Diseases of the Skin," Philadelphia,
1837.
Rigal, Aug. Art. " Langue," " Nouv. diet, de med. et de
chir.," vol. xx, Paris, 1875.
Saison, C. " Syphilides sur la langue," Paris thesis, xlvi,
1871.
Salter, S. James A. " On Papillary Tumors of the Gum,"
1866.
Schwimmer, Ernst. " Die idiopathischen Schleimhaut-
Plaques der Mundhohle ; Leucoplakia buccalis," " Vierteljahres-
schrift fur Dermat. und Syph.," iv, v, 1877, 1878. See " Trans-
actions of the International Med. Congress," vol. iii, 1881.
Trelat, . Relations between psoriasis and epithelio-
ma of the tongue, " Bull, et m6m. de la soc. de chir.," vol. i,
1875, and vol. ii, 1876.
Ullmann, . " Schwielenbildung auf der Zunge,"
"Aerztlich. Intelligenzblatt," Munich, v, 1858.
Vidal, E. Clinical lecture at the Hopital St. Louis on buccal
leucoplasia, "L'Union med.," xxxv, 1883.
Weir, Robert F. " Ichthyosis of the Tongue and Vulva,"
« New York Med. Jour.," xxi, 1875.
NOTE ON THE USE OE ANTIPYRINE IN
SUN ST HOKE.
By BENJAMIN F. WESTBROOK, M. D.,
PHYSICIAN IN CHIEF TO THE DEPARTMENT OF DISEASES OF THE CHEST.
ST. MAHY'S GENERAL HOSPITAL, BROOKLYN.
My object in publishing this note is to call attention to
the use of antipyrine in two cases of sunstroke, so that others
may, if they think proper, test it and contribute the results
of their experience.
It occurred to me that the prompt introduction of an
antipyretic dose of this substance into the subcutaneous
tissues might be of great service in reducing- the tempera-
ture, and so give time for attention to the treatment of the
other pathological conditions. The ambulance surgeon, Dr.
Polker, was therefore requested to provide himself with a
fifty-per-cent. solution, and, in the event of his being called
to a case of the apoplectic form of the disease, to administer
a drachm of the solution hypodermically at once, and to re-
peat it in an hour, if the temperature was not markedly
reduced. Other measures for the relief of the patient were,
of course, not to be neglected.
On Saturday, the 18th, when the thermometer registered 99'
F. in the shade, he was called to attend a young Englishman,
twenty-two years old, of very robust habit, who, after working
out of doors all the forenoon, became comatose and convulsed
after reaching his home at midday. The head was congested,
eyes suffused, pulse rapid and strong, skin dry, and the coma
profound. The bowels had moved spontaneously, and he had
vomited freely. The rectal temperature was 109° F. The doc-
tor administered a drachm of the fifty-per-cent. solution of anti-
pyrine hypodermically, applied ice to the head, and removed
him to the hospital.
In the confusion attending his admission the exact time was
not noted, but in about three quarters of an hour after the first
dose the rectal temperature was 107-50° F. Cold was applied to
the body and head by means of towels wrung out of ice-water
and frequently changed; and another drachm of the solution
was introduced under the skin. In thirty minutes the rectal
temperature was again taken and found to be 99° F. The cold
applications were at once discontinued and dry heat was ap-
plied to the surface, while whisky was injected subcutaneously.
When I arrived shortly afterward the surface of the body
was cool, the pulse 120, the coma profound, and all the limbs
were twitching convulsively. The head was still congested,
the conjunctivae injected, the pupils contracted but responding
feebly to light, and the respiration was irregular and accom-
panied by a loud expiratory groan, such as is heard in severe
cerebral disturbance. I gave two ounces of whisky and forty
grains of chloral hydrate by enema, but they were not retained.
About half an ounce of whisky was then given hypodermically.
In half an hour the temperature began to rise slowly, so that
the surface was warm. The twitching of the voluntary mus-
cles became more marked, and he was seized with a most vio-
lent tetanic convulsion, which was controlled by chloroform.
As the convulsions succeeded each other with increasing rapid-
ity and intensity, I opened the median basilic vein and with-
drew thirteen ounces of blood. The bleeding was terminated
sooner than was desirable by the onset of a terrific convulsion,
during which the arm was twisted violently and the opening in
the vein occluded. After this there were no more severe con-
vulsions ; the patient became more quiet, and the rectum re-
tained forty grains of chloral hydrate. This was followed by a
July 25, 1885.]
STUB: CHOLERA ASIATIC A
AND CHOLERA NOSTRAS.
93
period of rest, during which the axillary temperature was taken
and found to be 103-75° F.
One drachm of Lente's solution was thrown under the skin,
and repeated about once in two hours till four doses were ad-
ministered. At 8.15 p. m., as slight convulsions had occurred
from time to time, six leeches were applied to the temporal
regions, twenty grains of antipyrine given hypodermically, and
forty grains of chloral hydrate by the rectum. From this time
on- he slept quietly, the temperature slowly declining until Sun-
day morning, when it was 99° F.
At about ten o'clock on Saturday evening the patient first
became sufficiently conscious to partially respond when spoken
to, and from this he passed into a condition of hebetude, which,
by Monday forenoon, had given place to complete conscious-
ness. The temperature has been normal since Sunday after-
noon, though the pulse is still somewhat rapid. He takes nour-
ishment well. From Sunday morning to Monday morning he
had forty grains of sodium bromide every two hours, and five
grains of the sulphate of quinine every four hours. The doses
were then reduced to twenty grains and two grains.
This case represented the severest type of sunstroke. I
have never before seen so bad a one recover. The tempera-
ture was high, the coma very profound, and the convulsions
the most terrible that I have ever witnessed, except in. one
case of tetanus, the subject of which died within twenty-four
hours after the diagnosis was made. The rapid and per-
manent reduction of temperature, which must have been
mainly due to the antipyrine — inasmuch as the cold appli-
cations were only continued for half an hour — undoubtedly
contributed toward the favorable result by giving time and
removing at once the injurious effect of the hyperpyretic
blood upon the higher nervous centers. The beneficial
effect of the abstraction of blood was evident.
The second case was brought in an hour or two after
the first, and while I was in the hospital :
The patient, an Italian laborer, had been engaged in some
laborious work upon the new btfilding of the St. John's Orphan
Asylum, which was destroyed by fire last winter. He became
suddenly unconscious, had well-marked convulsions, and voided
his excrement involuntarily. When Dr. Folker, our very com-
petent ambulance surgeon, arrived he was comatose, breathing
irregularly, with rapid and tense pulse, suffused conjunctivae,
dry skin, and continual convulsive twitchings of all the volun-
tary muscles. The rectal temperature was 110° F. The doctor
gave him a hypodermic injection of one drachm of the fifty-per-
cent, solution of antipyrine, applied ice to the head, and brought
him to the hospital. On his admission he was comatose. The
surface, to my surprise, was cool. The pulse was 120, as nearly
as it could be counted, with marked tension and a laboring
stroke of the heart. The respiration was rendered irregular by
the continued spasmodic movements of the voluntary muscles.
The convulsive movements of the limbs were very peculiar,
differing from any that I had seen before, in that they were
rhythmic in character, and most readily likened to those of a
man pulling upon a rope. The rectal temperature, thirty-five
minutes after the administration of the hypodermic injection
containing one half drachm of antipyrine, was 101° F.
No cold applications were used in this case, with the excep-
tion of ice to the head. He was given, by enema, four ounces
of whisky and thirty grains of the hydrate of chloral, and re-
tained it.
After a time he became quiet, the convulsive movements
almost entirely ceased, and consciousness became dimly percep-
tible. But, upon changing him to another bed, the peripheral
irritation threw him into an active tetanic convulsion, which,
however, soon subsided spontaneously. It was noted afterward
that any pronounced peripheral irritation would produce con-
vulsive movement. After an hour he received another half-
drachm dose of chloral hydrate, with two ounces of whisky, per
rectum.
He also received a drachm of Lente's solution of quinine
about once in two hours. On Sunday morning he was quite
conscious. The temperature was 99° F. He was ordered
twenty grains of the bromide of sodium every two hours and
three grains of quinine every four hours. On Monday his con-
dition was still better, his mind, apparently, quite lucid, and his
desire to move about and partake of food very decided. The
bromide and quinine were continued.
The favorable termination in both of these cases is sig-
nificant, as they were both accompanied by great hyperpy-
rexia and signs of a most profound vital disturbance. The
first case was, probably, slightly injured by the use of cold
applications too long continued, but this was quite excusa-
ble on the part of the house staff, as they were dealing
with a new remedy, and had been advised not to neglect
the old ones. The result in the second case would seem to
strongly indicate that, where antipyrine is used, the exter-
nal application of cold is not necessary. Another interest-
ing observation was that, when the temperature declined,
the cerebral symptoms still continued. This might indicate
that even a short period of such intense heat and arterial
excitement may so benumb the vaso-motor apparatus that
several hours are required for recuperation.
If this is the correct inference, an agent like antipyrine,
which is capable of reducing the temperature quickly, may
be of the utmost importance.
But, of course, further observation is necessary before
any positive conclusion can be drawn. From our experience
so far, I should say that half a drachm of the drug would
be sufficient to accomplish the purpose. A fifty-per-cent.
solution is easily made, and, when injected beneath the
skin, produces very little irritation.
CHOLERA ASIATICA AND CHOLERA
NOSTRAS ;
THEIR DIAGNOSIS AND TREATMENT,
WITH SPECIAL REFERENCE TO THE BACILLUS. *
By ARNOLD STUB, M. D.,
BROOKLYN.
(Concluded from page 36.)
Those spirilla discovered by Deneke in cheese, and by
Lewis found in the mucous covering of the teeth, I have
nothing to do with in this paper; it will be sufficient, I
think, to mention that they also present different appear-
ances on cultivation, and that Dr. Lewis's bacillus does not
grow at all in alkaline or neutral nutritive gelatin. If a
small particle is taken, with a previously well-sterilized pla-
tinum wire, from one of the colonies recognized as Asiatic-
cholera bacilli, and gelatin kept in a test-tube inoculated
with the same, we shall find that within forty-eight hours,
at 68° F., from the time of inoculation, a whitish turbidity
94
STUB: CHOLERA ASIATICA AND CHOLERA NOSTRAS.
[8. Y. Med. Jodr.,
will start, in the immediate neighborhood of which the gela-
tin will become liquefied ; but tins process is so slight that
only a very fine capillary tube will be the result, which
becomes a little wider toward the surface. The top of this
tube is generally below the level of the solid gelatin, and
upon the top of the tube we generally see an air-bubble.
The liquefied gelatin remains clear, and only upon a few
places do a few whitish masses appear. After four to six
days the gelatin will be sufficiently liquefied to reach the
walls of the test-tube. The spirillum of cholera nostras,
however, is characterized by its very energetic liquefying
action upon gelatin.
"Within twenty-four hours it has formed a wide tube
filled with a diffuse opalescent fluid, and the surface of this
tube extends to the walls of the test-tube. The lower end
of the tube is widened out sack-like. I may add also that
the cholera spirillum does not grow upon potatoes at a tem-
perature less than 86° to 88° F., and from 98£° to 99£° F.
it forms a dark-brown paste upon the surface. The spi-
rillum of cholera nostras grows beautifully upon potatoes- at
64*5° F., and forms a yellowish-gray covering.
However, before I proceed to make a cultivation of the
bacilli to be found in the alvine evacuations, I first make
an attempt to relieve the patient by a hypodermic injec-
tion of sulphate of morphine and atropine. I order fric-
tions with soap liniment, chloroform, and laudanum to the
body ; also sinapisms alternately applied to the extremities
and epigastrium, hot flat-irons or bottles filled with hot
water to the soles of the feet, and try to administer a good
dose of 10 to 15 grains of calomel internally, and order the
same to be continued in small doses of about two grains
every two hours.
I certainly shall not give bismuth, either the subcarbo-
nate or the subnitrate, because I wish to avoid everything
which tends to make the contents of the stomach and
alimentary canal more alkaline. I do not expect anything
from the calomel except from its property as a mercurial to
destroy the cholera germ by acting as a poison directly upon
the latter; and perfectly agree with the views of Dr. Pallen,
of New York, who published the same in the " Medical Rec-
ord" of March 7th, and who contended that during cholera
the stomach and alimentary canal were not capable of assimi-
lating any medicine whatsoever. For this very reason I
shall also continue the hypodermic injections at proper
intervals, and in accordance with the urgency of the case.
Later on, when the condition of the patient requires it, I
shall also administer brandy hypodermically.
But, gentlemen, I shall also remember the results of the
treatment of Professor Cantani, of Naples, who, during the
last epidemic, resorted to acidulated enteroclysmata of a
temperature from 103° to 104° F. According to Koch, one
part of carbolic acid to 400 parts of water is sufficient to
prevent the increase of the cholera bacilli, and, although we
should not be justified in administering such a clysraa to a
healthy person, I believe that, in case of cholera where all
the powers of absorption by the intestinal canal were sus-
pended, we might perhaps be able to resort to this propor-
tion with benefit to the patient. Although Professor Ar-
rnanni, of Italy, has found the microbes principally in the
colon and caecum, and a number of cases have been treated
with simple "medicated enemas with benefit, in severe cases,
where the inroad of the microbe extends higher up, it will
be necessary to resort to an enteroclysma which will reach
beyond the ileo-caecal valve.
Of all substances, however, which prevent the reproduc-
tion of the cholera bacillus, the bichloride of mercury stands
foremost. Oil of peppermint has this property in the propor-
tion of 1 to 2,000, sulphate of copper 1 to 2,500, quinine 1
to 5,000, and the bichloride of mercury 1 to 100,000. For
this reason I would try the sublimate in combination with
hydrochloric acid : first as an ordinary enema, and later on,
if I found the disease make progress and the case become
desperate, as an enteroclysma. If, however, I were able
to dust the whole of the alimentary canal over with calomel
in the same manner as we sprinkle iodoform over an ulcer-
ated surface, I think I should prefer the latter method to
kill the microbe.
I am not aware that the sublimate has been tried in the
manner proposed by me, and I certainly would abstain from
its use in the beginning of the disease and before the faculty
of absorption had ceased. The algid stage, I think, would
be the proper time to begin with, and previous to it I should
confine myself simply to copious enemas' of hot water acidu-
lated with hydrochloric acid, and administer the latter also by
the mouth in the form of an iced lemonade to relieve thirst.
Whether an occasional enema or an enteroclysma of hy-
drochlorate of quinine, dissolved in hot water and acidulated
with hydrochloric acid, would be desirable, I think a mat-
ter worthy of consideration.
Gentlemen, we put a typhus-fever patient into an iced
bath with the view of reducing his temperature. Would it
be unscientific and unpractical to put a cholera patient into a
•permanent hot bath with a temperature, say, of 104° or over
to increase his temperature ?• Koch considers the manner in
which the cholera bacillus produces certain changes in the
system a poisoning process, and states that in his opinion
the poisonous properties of the bacillus act with paralyzing
influence upon the circulatory apparatus, and, although this
seems to be only theoretical so far, it would explain the fact
that hot baths have proved of benefit in cholera. I must
also allude to the transfusion of salt water into the venous
system as advocated by Dr. Kronecker, who also gives a
description of an apparatus to be used for the purpose, and
who condemns the practice of intra-abdominal and subcu-
taneous injections, frequently resorted to during the last
epidemic in Italy, on account of the impossibility of regu-
lating the time when the injected fluids may enter the cir-
culation.
During the same epidemic the following treatment was
adopted. Cantani, Paoluzi, and particularly Dr. Yitone,
speak of the excellent results of a clysma composed of
Inf. flor. camomill (38° C.) 2 litres;
Acid, tannic 3,0-6,0 grammes;
Gumm. arab 30,0-50,0 "
Laudanum 30,0-50,0 "
which, freely administered, caused intermissions of from six
to twelve hours. With all internal remedies for the pur-
July 25, 1885.]
STUB: CHOLERA ASIA TWA AND CHOLERA NOSTRAS.
95
pose of disinfecting no result has been obtained. But all
Italian authorities agree that subcutaneous injections of
morphine have been of benefit. Of special benefit, how-
ever, have been irrigations per rectum of carbolic acid, sub-
limat, iron sulphate, and quinine.
In the algid stage Cantani has resorted, with considera-
ble benefit, to subcutaneous injections of salt water of the
temperature of about 100° F. and in the proportion of thirty-
four ounces of water, sixty grains of table-salt, and forty-five
grains of carbonate of sodium.
He observed in the severest cases an abatement of all
the urgent symptoms within a few minutes after this enema
had been given. During the stage of asphyxia, subcutane-
ous injections of ethereal tincture of valerian, ether, and
sulphate of caffeine were used.
The Italians also speak highly of hot baths and of the
inhalations of oxygen. Cantani especially mentions that
during convalescence we must be careful to avoid milk and
beef-tea or meat broths of any kind, because the comma ba-
cillus is apt to grow in those media and a relapse may be
the consequence. But between the two he would prefer
meat broths, because he found that milk never did agree
with his patients. His meat broths he acidulated with
hydrochloric or lactic acid. In case, after the strength of
the patient has returned, vomiting persists in consequence
of hyperesthesia of the stomach, he recommends ether and
chlorodyne, or cherry-laurel water with morphine or bella-
donna.
Dr. Dornbluth, of Rostock, recommends calomel to be
given as I have recommended before, and particularly in
the typhoid stage he calls attention to resorcin and cotoin.
He speaks highly also of subcutaneous or intravenous injec-
tions of salt water, to overcome the thickening of the blood.
During the epidemic in Toulon the treatment of the so-
called cholera diarrhoea consisted of
R, ^Ether 1,0;
Tinct. opii gtt. xv-xx ;
Ext. kramerhe 1 ,0 ;
Syr. cort. aurant 30,0 ;
Aq. melissa? 120,0.
Against the vomiting, every quarter of an hour a tcaspoonful
of Chartreuse, sometimes bismuth and opium.
In more serious cases this treatment is combined with
injections of warm wine and laudanum, carbonic-acid water
cooled on ice, and, against profuse diarrhoea, water saturated
with oxygen gas, to which I personally beg leave to object,
as the cholera bacillus belongs to the species of aerobe bac-
teria and requires oxygen to develop. Frictions with ol.
terebinthime, opodeldoc, and chloroform are used. Hypo-
dermic injections of morphine in the epigastric region are
particularly mentioned by Dr. Cuneo, physician-in-chief of
the navy of France, who has found great benefit from the
hypodermic injection of half a centigramme of hydro-
chlorate of morphine with one quarter of a milligramme of
atropine. Spasm of the muscles of the lower extremities he
has treated successfully with hypodermic injections of ether.
During the stage of asphyxia, injections of ether pro-
longed life for a few hours in a few cases, but subcutaneous
injections of atropine sulphate, first one half a milligramme
and afterward one milligramme, from four to five times in
twenty-four hours, caused a rise of temperature of 2° in one
case.
He also professes to have saved six patients with inhala-
tions of pure oxygen by means of a mask and a tube, the
latter introduced into the nares. In those cases where cold-
ness and cyanosis did not form the prominent symptoms, this
treatment, which he, by the way, repeated every half-hour,
and continued for two minutes each time, gave no results.
The question of prophylaxis requires consideration in
this paper, and I would like to call attention to the remarks
made at the meeting of the Imperial Board at Berlin, July
24, 1884, by Dr. Leyden, that a certain immunity exists
against a second attack of cholera, although this immunity
does not seem to be absolute, and it is well authenticated
that persons have been attacked by cholera in one epidemic
and died during a second attack in another epidemic.
More rare, however, is the fact that a person has been at-
tacked more than once during one epidemic, although Dr.
Wievioroevski quotes the case of a patient who was taken
sick August 13th, left the hospital well on the 20th, and
was taken sick again with cholera on the 5th of September,
and died.. Dr. Koch, however, thinks that such cases must
be very rare, and seems to be of the opinion that one attack
secures the person against a second attack during the same
epidemic in most cases. Perhaps being impressed with the
same views, a Spanish physician inoculates his clients with
the comma bacillus, as I have read in a daily paper. It is
remarkable, however, that the medical papers are silent upon
the subject, or that they only give short notices of Dr. Fer-
ran's investigations.* If Dr. Ferran's microbes are identical
with Koch's bacillus, it would appear impossible to inoculate
them into the blood with any chance of success, because the
circulatory system does not seem to be the home of this
parasite. In none of the post-mortem examinations Koch
has made could lie detect this parasite outside of the ali-
mentary canal, and only very rarely in the contents of the
stomach. If found in the latter, it has been only in cases
where a process of regurgitation had caused faeces to enter
the stomach. The blood and other fluids of the body are
not invaded by the bacillus, and not a single case is on
record where infection has taken place from a post-mortem
examination. Whether Koch's comma bacillus assumes
different properties if cultivated and recultivated upon dif-
ferent nutritive media, is a question which later investi-
gations will certainly solve. If I may venture upon an
opinion at all in this matter, it is that, if artificially culti-
vated bacilli have the property of causing immunity from a
severe attack of cholera, they should be introduced into the
intestine and not into the circulation. The question natu-
rally forces itself upon me, Is this microbe of Dr. Ferran's
actually identical with Dr. Koch's bacillus, or is it the same
Dr. Emmerich, of Munich, has discovered in the blood and
in the tissues of the whole body of persons who died of
cholera ?
* Only the "Deutsche medicinische Woehonschrift," of Berlin, April
20, 1885, speaks of the fantastic views of Dr. Fenan in reference to
his inoculation of the bacillus.
96
STUB: CHOLERA ASIATIC A AND CHOLERA NOSTRAS.
[N. Y. Med. Jocb.,
Dr. Emmerich also cultivated his bacterium, and inocu-
lated various animals with the same. They all died, but
post-mortem examinations seem to have revealed the fact
that Peyer's patches were ulcerated, which led critics to
assume that those animals did not die of cholera but of a
septic poison. Koch has made about one hundred post-
mortem examinations in Egypt, India, and France, and in
all cases the result has been the following. He divides
the results of his investigations into three different varieties.
First, he mentions cases where the lower part of the ileum
and caecum, and particularly above the ileo-cajcal valve, had
assumed a dark-brown, reddish color, the mucous membrane
being studded upon the surface with hemorrhagic exuda-
tion. In a few cases he found diphtheritic patches, and
the membrane almost necrotic. In accordance with this,
the contents of the bowels were not of rice-water appear-
ance, but a bloody, stinking fluid. In the second class
of cases the redness was less marked, being only by spots,
and in some cases only the edges of the follicles and
Peyer's patches were reddened. The last form he considers
to be particularly characteristic; it does not appear in any
other affection of the alimentary canal, and seems to be
peculiar to cholera.
In comparatively few cases did he find the mucous
membrane little changed ; it looked swollen and less trans-
parent in the upper layers, the solitary follicles and Peyer's
patches were more prominent, the whole of the mucous
membrane was of a light rose color, but in no case was
there capillary bleeding.
In those cases which constitute the third class the con-
tents of the bowels were colorless — not always like rice-
water, but more like water which had been mixed with
flour. Only a few cases came to his notice where the
contents of the bowel were a watery mucus ; the reddened
edges surrounding Peyer's patches contained the most of
the comma bacilli. All the animals which died after be-
ing injected with the virus presented the same symptoms
and the same post-mortem appearances. Numerous experi-
ments to this effect have recently been made by Koch,
Klob, Nicati and Rietsch, Cantani, and others, and all to the
same effect. In addition to the foregoing, I may state that
the spleen in cholera cases, and in animals which died after
being injected with the cholera bacillus of Koch, has al-
ways been found atrophied. It seems that the spleen of
animals inoculated with the bacterium of Emmerich was
found to be the reverse. In my opinion, all the experiments
made upon animals must be accepted with caution as re-
gards their bearing upon the cholera-germ question, because
no cases are on record in which an animal ever has taken
the cholera during any of the great epidemics in India and
in Europe. They seem to enjoy an immunity from this
disease, and whether we are able to produce it artificially or
not is a question not yet solved to my satisfaction.
After this digression, I beg leave to mention one prophy-
lactic which enjoys a reputation with some medical men
up to the present time. It is the sulphate of copper, to be
taken daily in very minute doses, during the whole course
of an epidemic. The French particularly seem to have
been impressed with this belief, and Burq, the father of
metallotherapy, recommended it in 1857. French medi-
cal papers also quoted instances where large bodies of
troops marched through cholera districts and enjoyed im-
munity from the disease, which was explained by the fact
that they had been constantly dosed with the copper during
the time they traveled through the infected locality. Dr.
Garrigues, formerly of this city, stated to me that he at-
tended a hospital with six hundred cholera patients, during
the year 1864, at Copenhagen; that he took daily small
doses of the copper, and did not get the cholera, but, as he
remarked, other physicians in the same hospital, who also
did not get the cholera, did not take the copper.
Gentlemen, I think the best prophylactic will be to
avoid everything that tends to derange our digestive organs,
and which may give rise to an intestinal or gastric catarrh.
The healthy gastric juice will certainly kill the cholera
germ; but an alkaline condition of the contents of the
stomach will be the means of its passing into the intestinal
canal, and then the mischief begins. I would, perhaps, rec-
ommend taking small quantities of hydrochloric acid every
time we drink water. I should certainly prefer distilled
or, at least, boiled water to the ordinary drinking-water.
Although the bacillus can not live longer than two days
and can not reproduce itself in pure water, the ordinary
drinking-water may contain enough of the germ to infect
us. The same with milk ; it should never be used unless it
has been boiled first ; then milk in particular forms a good
nutritive medium for the microbe.
In the rooms of the sick I would strictly enforce the
rule that nobody should be allowed to eat or drink except
the patient, and I would urge upon the attendants to wash
their hands with a solution of bichloride before taking food.
I would not trust to any other disinfectants in the rooms of
the sick, unless later researches should give us practical proof
that some of the articles of commerce now in the market,
and highly extolled as disinfectants, will stand the scientific
test against cholera germs. It seems that all acids are not-
destructive to the cholera germ, as is proved by the fact that
it will grow upon freshly cut potatoes, and such a fresh cut
has an acid reaction. For this reason I would advise to
abstain from the use of fruits, apples in particular, because,
besides that they have the faculty of rendering the contents
of the stomach alkaline, they may also be the direct means
of introducing the bacillus into the stomach. In using dis-
infectants we should strictly avoid those which retard putre-
faction, for it has been amply proved that the bacillus of
putrefaction is the deadliest enemy of the comma bacillus,
and that wherever the former appears the latter disappears.
To put sulphate of iron into a cesspool containing excre-
ments of human beings during a cholera epidemic would
prepare a good nutritive element for the germ. I would
like to call the special attention of our Board of Health to
the cesspools of our public resorts, particularly to those of
Coney Island. If no proper care is exercised in disinfect-
ing the same, they may be the cause of much suffering.
Bichloride in liberal quantities, often applied, will be the
only means, in my opinion. Not those means which only
deodorize come into consideration in this momentous ques-
tion, but those disinfectants which kill the germs of the
July 25, 1885.]
STUB: CHOLERA ASIATIC A AND CHOLERA NOSTRAS.
97
disease. The best of all means of killing the cholera bacil-
lus is dry heat. If it is subjected to a drying process, it
will die within a few hours. For this reason I mentioned
before that I did not think the importation of rags from
Europe could import the disease also, because all rags,
before they are shipped for commerce, are subjected to a
drying process. For the reason that dry heat kills the
germ, I would recommend stopping the sprinkling of the
streets during an epidemic of cholera, and I would also
recommend that all the bed-clothing of cholera patients,
and all the personal wearing apparel used during their ill-
ness, be subjected to a process of dry heat. If all the ex-
crements could be destroyed by fire, it would be better
still ; but, as such a process would be difficult or impos-
sible to accomplish, let us boil, at least, the clothes in a
solution of bichloride, and then subject them to a process
of drying in a hot stove, and, if they burn, it will be all
the better. No wet clothing of cholera patients should be
allowed to hang out in the yards or upon the roofs of houses
to dry, there is such a possibility of a strong draught of
air taking up the germ and carrying it to a soil where it
may grow and increase. Gentlemen, you will remember the
appropriate remarks made by the medical officer of the
navy who visited our last meeting. You will remember
that he told us that during a time when cholera was raging
in India a United States man-of-war was lying in the Ganges
in midstream, and none of the officers or crew took the
cholera. Why did that happen ? First, the proverbial
cleanliness on board of a United States man-of-war, and,
second — and may be, perhaps, first — because they drank
only distilled water.
Although I told you that the comma bacillus could live
only a few hours in wrater, and did not multiply there, it
may grow upon the soil of the banks of a river, provided
the soil happens to have some of the elements necessary for
its reproduction. The stream of water may carry the germ
along, and by that means become the cause of the disease
— one reason more why we should drink only distilled or
boiled water during those times, and why we should not
sprinkle the streets. I beg leave to mention that Dr. Koch
spoke to the Medical Society of Marseilles, and stated that,
in his opinion, chloride of lime must not be relied upon as
a means for disinfection. He advises keeping a five-per-
cent, solution of cai'bolic acid in all vessels used in the room
of a cholera patient. The best means of destroying the germ
he considers hot steam, which must be used with an appa-
ratus from which a jet of steam issues of a temperature of
100° C. Such a system may well be carried out in hospitals,
etc., but in private dwellings, tenement-houses, etc., it will
be impracticable, and I think boiling with a strong solu-
tion of bichloride, and afterward drying in a hot stove, will
answer our purpose in private practice. The solution of
sublimate which he recommends as wash-water for the hands
of nurses and physicians who attend cholera patients should
be of the strength of 1 to 1,000. Koch also urges to avoid
drinking water unless it has been previously boiled, and he
himself, during his stay at Marseilles, drank only mineral
waters, and always washed his hands in a solution of subli-
mate before he took his meals. He strongly urges the
washing of all cooking utensils, glasses, etc., with boiling
water, and is of the opinion that, although beer in all proba-
bility does not contain the microbes, the water in which the
glasses have been washed may do so, and thus cause in-
fection. Gentlemen, I am of the opinion that our system
of sewerage, our water supplies, etc., and the general sani-
tary condition of this city, thanks to the efforts of the
Board of Health, are such that we may consider ourselves
well prepared to meet the enemy if he attempts an inva-
sion.
We hear of unclean streets, and in some parts of the
city an improvement would be desirable, but, on the whole,
we may compare well with such cities as Naples, Toulon,
or Marseilles. Although it may be comfortable to con-
template this condition of affairs, vigilance in sanitary mat-
ters must not cease, and we, as physicians, should be will-
ing to lend a helping hand to the efforts of the Board of
Health to suppress an epidemic by reporting every suspect-
ed case as soon as it occurs. I contend that private inter-
est must not be taken into consideration as long as the
public welfare is at stake.
I have not mentioned in this paper the report of the
English commission which was sent to India to investigate
the cholera. The exact words which Dr. Klein used in his
report, March 24th, before the Royal Medical and Chirurgi-
cal Society of London, copied from the London " Lancet "
into the " Deutsche medicinische Wochenschrift," April
16, 1885, are the following: "Comma bacilli of various
species have been discovered in other diseases of the ali-
mentary canal, in the fluid of the mouth of normal per-
sons (Lewis), and in old cheese (Deneke). The comma
bacilli found by Finkler and Prior in cholera nostras differ
in mode of growth from Koch's comma bacilli of cholera ;
so do those found in diarrhoea due to other causes ; but
those of the fluid of the mouth are identical with Koch's
comma bacilli in many respects."
He admits, consequently, that they are not identical in
all respects, and I may refer you to my former remarks that
Dr. Lewis's bacilli do not grow upon alkaline nutritive gela-
tin. I would recommend to all those of you gentlemen
who wish to be informed upon the subject of the cholera
bacillus to read the reports to the Scientific Grants Com-
mittee of the British Medical Association, by W. Watson
Cheyne, Assistant Surgeon to King's College Hospital, etc.,
and Research Scholar of the British Medical Association, as
published in the "British Medical Journal." One of the ar-
ticles published in the "Journal " of May 2, 1882, I have seen
throusrh the kindness of Dr. Hunt, and I found it to be such
a lucid and true expose of Koch's discoveries that 1 beg
leave to mention it here. It gives all the illustrations,
partly after Koch, and in a great measure after Mr. Cheyne's
own investigations, and mentions also the later highly in-
teresting researches of a Mr. E. M. Nelson in reference to
the discovery of the flagella of the bacillus, before unknown
to me. I would not have mentioned Dr. Klein's report in
this paper, because I considered the matter as settled, had
not an allusion to it been made at our last meeting, and if
the president of the Medical and Chirurgical Faeultj of
Maryland, at the annual session, May 12th, as reported by
98
MILLS: RIOQS'S DISEASE.
[N. Y. Med. Jode.,
the "Medical Record," May 10th, had not stated in his
opening address, " Origin and Diffusion of Cholera," that
he " did not consider the parasitic origin of the disease
proved, because Kocli had not succeeded in producing the
disease by injecting the comma bacilli, and Lewis had dem-
onstrated the presence of bacilli in the human system under
other circumstances." But not alone Koch, but Klob,
Rietsch, Xicati, and others have successfully injected the
comma bacillus into the intestines of animals, as already
stated before, and Lewis's bacillus is certainly not identical
with Koch's. Gentlemen, if a physician has a suspected
case of kidney disease, he is expected to test the urine
for albumin, and examine into the percentage of urea and
look for casts, etc. ; but, when it is necessary to make a quan-
titative analysis of the urine, lie will be obliged to get a
specialist to attend to the matter ; for, even if he has the
necessary knowledge and apparatus to do so, he has not the
time. If a hospital surgeon removes a tumor from a patient
he turns the specimen over to a pathologist for microscopi-
cal examination, and I think it will be the same with the
examinations of the excrements of suspected cholera cases.
We, as practical physicians, will be able to make the primary
examinations by cultivation and with the microscope; but
when it comes to further scientific researches into the mat-
ter, there our duty ends, and also our ability. A constant,
untiring observation, together witli the minutest attention
to details, is necessary to carry out the investigations, and
those of us who undertake to work further upon this tield,
with the hope of adding something new to the general
knowledge, will be sorry to find that they worked in vain
because they have no time for such researches. We have to
content ourselves with utilizing the discoveries made by
those who make it their sole study. If the German Gov-
ernment, however, thinks the matter of sufficient practical
importance to detail by turns all the medical officers of
the army to take a course in the laboratories of the board
of health at Berlin, to enable the army physicians to make
the necessary investigations for diagnostic purposes, I think
it will not be out of the way if I herewith respectfully
suggest that our Board of Health detail one of its mem-
bers to take a course at the lately established laboratory of
the Bellevue Hospital Medical College, for the purpose of
familiarizing himself with the technical methods of making-
such investigations, and if, with a little financial aid from
the city, the Board of Health could afterward establish a
laboratory for biological researches, it would materially fur-
ther rational sanitary purposes.
KIGGS'S DISEASE.
By G. A. MILLS.
At a meeting of the Connecticut Valley Dental Asso-
ciation, about eighteen years ago, at Northampton, Mass.,
John M. Riggs, M. D., of Hartford, Conn., was invited to
make a proclamation (associated with a clinic) of his views
concerning a diseased condition of the gums and the sockets
of the teeth which often causes the loosening and falling out
of the same. Hp to this time nothing had appeared in the
literature of dentistry except that which classed this dis-
order among the incurables, and it was spoken of as the
resultof senility; hence the common remark among people,
" My father's and mother's teeth all dropped out, and it is
only a matter of time with me." The removal of tartar as
an external deposit upon the teeth was classed simply as an
operation of scaling. This -operation only recognized the
foreign matter that could be seen. Dr. Riggs, in announc-
ing his original views — while he gave it as his opinion that
the deposits of tartar were the cause of the disorder under
consideration — stated that his observation and experience
matured the knowledge that there was a decided progressive
inflammation existing under the gums and wasting both the
hard and soft tissues, so that their attachments with the roots
were gradually being destroyed. His knowledge of surgical
principles suggested a practical application to these diseased
localities, and he proceeded to the removal of all foreign sub-
stances from the roots of teeth, and the trimming of the ne-
crosed edge of the alveolus to the life-line, leaving nature to
restore to a normal condition. Dr. Riggs's view naturally
excited a variety of comment — some expressing disbelief, and
others accepting his novel ideas and statements. Not a few
denied the existence of a necrosed edge of the alveolus. Dr.
Riggs had devised a set of instruments well adapted for the
treatment of this disorder — and these were unique and new,
yet there was an effort on the part of a very few to dispute
his claim to this invention ; this did not prove a success.
This body (the Connecticut Valley Dental Association) sub-
sequently passed a resolution giving credit to Dr. Riggs for
originality relative to the new pathology of the disorder
now termed Riggs's disease, and so named at about that
time in honor of Dr. Riggs. I have previously remarked
that nothing of the doctor's view-s had ever been published
so far as known. But — having become personally much in-
terested in this disease, and in the discussion of it, and
also finding my position regarding it misunderstood by sev-
eral dentists — I was led to prepare a series of articles (six),
which were published in the " Dental Cosmos " during the
years 1870 and 1877, under the title of " What I know-
about Riggs's Disease," in one of which articles I challenged
the record of views corresponding to Dr. Riggs's. Since then
not a word has come from any source to show that he is
antedated in the matter. I may add that a confirmation of
his views and their acceptance by many members of the
dental profession have gradually taken place. I am glad
to say that to-day it is the most prominent subject for con-
sideration before dentists generally. Only a limited num-
ber, however, have come to a correct understanding of what
is required and how to meet the requirements. These few
are demonstrating a successful treatment of the disorder.
At this point of my article it seems advisable to introduce
a feature which I shall elaborate later on ; it is in reference
to the technical term by which this disorder is now known
— viz., pericementitis, substituted for the term well known by
medical men — dental periostitis — meaning inflammation of
the dental periosteum. This term (pericementitis) origi-
nated in the laboratory of Charles Heitzman, M. D., of New
York city, during the late investigations made there by den-
tists under his instruction. The general subject of perice-
July 25, 1885.]
MILLS: RIGGS'S DISEASE.
99
mentitis it is not my design to discuss here, but it is neces-
sary to make the distinction clear between Riggs's disease
and general pericementitis. Riggs's disease is a peculiar
phase of pericementitis ; it may exist to the final loss of all
the teeth, without a sign of any other phase of this dis-
order.
As the nature of this disease is so plainly embodied in
my brief history of the matter which includes its pathology,
it would seem that my readers need not be ignorant of its
main features ; therefore I pass to consider the diagnosis.
To diagnosticate an incipient case, or first manifestation,
as it is often seen in the mouths of children (even at a very
early age) : The simplest form of the disease may often be
seen at the peripheral part of the festoon of the gum-tissue
indicated by a congested appearance; by lifting this gum
with a delicate instrument, there will be seen a little seed-
like granule of calcific substance. Another case might show
a deep red and raw-looking, elongated appearance of the
gum-tissue about the necks of the teeth, and with or with-
out any deposit; there may be also a looseness of the gum
about the .teeth, which causes quite a pocket. This latter
condition is often a sequela of exanthematous disorders.
The gums are often extremely sensitive to the touch. In
the various cases we find general congestion, easy haemor-
rhage, pale and bloodless gums, a decidedly anaemic and
frequently pimpled surface of the gums — the latter appear-
ance in adults. Not uncommonly a first warning to the
patient (adult) will be pain or tenderness about the tooth or
teeth, and an examination will not reveal any decay, death
of pulp (commonly called nerve), or evidence of inflamma-
tion of pulp. This is what I shall term a subtle manifesta-
tion, for it has been believed there could be no inflamma-
tion of the dental membrane without a disturbance of the
pulp. Th is is now proved to be untrue, for abscesses do
occur while the pulp remains normal. In a large propor-
tion of cases there will be, on light pressure, a flow of pus
from under the gums, and oftentimes it is a copious dis-
charge. This may be general, or it may be confined to a
single tooth. Looseness of one or more of the teeth may
be observed ; also malposition, and this commonly after an
occluding tooth is lost. I have given in detail enough of the
manifestations to lead one even superficially familiar with
unhealthy conditions to the diagnosis. It will be observed
that I have omitted other conditions of disease that are
manifested in the mouth, associated with the teeth and
allied structures — viz.: syphilis, salivation, and scurvy.
While in some instances these may be separated from the
disorder in question, yet they are sometimes complications.
I will mention another marked diagnostic feature associated
always with an active stage of the disorder, and that is
the odor which is distinctly noticeable to one familiar with
Riggs's disease. There are other local manifestations that
are, without doubt, largely influenced by the disease, but are
commonly classed as expressions of constitutional debility,
and still they may be wholly the result of the disorder un-
der definition. This is proved by the arresting of the dis-
ease when the disabilities referred to are removed. Reces-
sion of gum-tissue is often seen, and no apparent inflamma-
tory condition. While this is a peculiar phase, I maintain
it is the same disorder. My term for it is atrophy of the
gum-tissue — erosion of the tooth-structure, causing grooves
across and around the necks of the teeth, not infrequently
taking a serpentine direction. This also is a manifestation
of the same disorder, as it is arrested by the treatment which
will now be described.
Treatment. — As the nature of the disorder has proved
to be novel, so will the treatment appear, as Dr. Riggs
was the inventor of a set of instruments with which to
perform the operations required in treating the disease.
Each one is six inches in length, including the handle,
which is of ebony and steel, octagonal and tapered ; the
blades are seven eighths of an inch long, bent at an obtuse
angle. The instruments are in two pairs, and there are
two single ones. One pair has a knife edge and a safe
edge ; the other pair has the same, but these are reversed
in their bevels — made so for the purpose of working at a
different angle of the mouth, and from the operator instead
of toward him. The single ones are double knife-edged,
and differing in thickness of blade. Perhaps no better
idea can be given of the general form of the blades than to
say they resemble the half of a snipe's bill, the long, ovoid
point being particularly adapted to ferreting out the intri.
cate and deep-seated disordered parts of the hard and soft
tissues about the roots of the teeth. In their dimensions
they may seem ponderous to a novice, but in the hands of
an expert no instrument can be more efficiently" and deli-
cately used. It must now be seen, by the description and
location of Riggs's disease, that most of the operation is
under the gum-tissue and out of sight, so that necessarily
to know when the operation is complete at a given point
can only be accomplished by an acquired and acute sense of
touch. It may be said that the Riggs treatment has in-
stituted a distinct and systematic mode of arresting the
disease. Rightly understood and rightly practiced, I re-
gard this treatment as the most efficient in dental surgery.
The severity of the cases differs according to constitutional
conditions, and, if the dentist is the doctor, he will know
whether the patient can be wisely aided by constitutional
treatment. The prognosis must be based upon the condi-
tions as they appear in each case.
From an extensive experience within the last ten years
in the treatment of a large number of cases, and the success
attained, I am justified in saying that Riggs's disease can
no longer be classed among the incurable ones.
It is perfectly plain that this disease is not confined to
any one period in life. Under the age of forty I have had
numerous cases in the most active stages of progress — so
noticeable that there was almost spontaneous haemorrhage of
the gums, and such an excessive flow of pus that the service
of napkins for absorbing was required in sleeping hours.
These facts can be testified to by well-known physicians.
As one impressed with the prevalence of Riggs's disease,
and its destructive effect on the general health, I should be
remiss in duty if I were silent, or neglected to call the ear-
nest attention of medical men and the public to the grave
facts, for they have had too little consideration. I would
say emphatically that the most serious complications may
arise, and the worst septic conditions may be threatened
100
BOOK NOTICES.
[N. Y. Med. Jock.,
and encountered, from pure neglect. That one disorder
not arrested calls others of a more serious nature into ex-
istence is a well-known fact among medical men.
Dooh Botites.
A Text-Book of the Principles of Phytic*. By Alfred Daniell,
M. A., Lecturer on Physics in the School of Medicine, Edin-
burgh. London: Macmillan & Co., 1884. Pp. xx-653.
[Price, $5.]
This book is intended to be used in the preliminary medical
course. The author justly lays stress in the preface upon the
importance of the study of physics, and the close relation be-
tween that branch and the department of experimental physi-
ology. He states that it is his express purpose to avoid the in-
troduction of " anything of the Dature of an unsolved riddle "
into his work. But the reader will rind himself greatly in error
if he regards this as an elementary treatise; a mere glance at
the table of contents will assure him that he has not entered
upon a course of light reading. The subject-matter is arranged
in an ascending series. Beginning with introductory sections
upon matter and its properties, we soon reach a solid chapter
on "Kinematics," under which are included wave-motions and
their demonstration by the aid of the higher mathematics. We
prophesy that this will prove a tough morsel for the student,
especially if he approaches it without a previous knowledge of
the subject.
Under " Kinetics" are included the familiar problems of the
lever, inclined plane, screw, and wedge, with a paragraph on
friction. " Attraction and Potential " and " Gravitation and
the Pendulum " form the subjects of Chapters VII and VIII.
Chapters IX, X, XI, and XII include "Matter," "Solids,"
"Liquids," and "Gases." With Chapter XIII we begin an ex-
haustive consideration of " Heat," which is fully up to the latest
theories. This is followed by " Sound," " Ether-waves " (as the
author calls bis chapter upon light), and a concluding disserta-
tion upon " Electricity and Magnetism." An exhaustive bibli-
ography and an excellent index conclude one of the most
scholarly works on physics that we have ever had the pleasure
of perusing. We regret that we can not give a more extended
notice of the book, but this is hardly permissible in a strictly
medical journal. The reader who is prepared to give his close
attention to every page is advised to look it over for himself.
A superficial reading is worse than useless, for, as we before
stated, this is not light literature. The criticism which we ven-
ture to offer upon the volume as a whole is that it is entirely
too advanced for the class for whom it is written. When we
remember that the average medical student has not enjoyed a
university education, we are compelled to believe that many of
the pages of formula? and mathematical demonstrations will be
quite beyond his grasp. As for the "general reader," whom
the author also includes among his audience, it will be a very
intelligent general reader indeed who profits by some of the
more abstruse paragraphs.
None of the familiar illustrations of physical apparatus have
been introduced (we think unwisely), but their places have been
supplied by numerous geometrical figures, often quite compli-
cated. We do not wish to underrate the ability of our Ameri-
can medical students, but we must confess that few of them
would take pleasure in physics with such a text-book. A little
less of mathematics and a little more of the practical applica-
tion of theories would be highly desirable.
The volume is a model of neatness and accuracy. The clear
type, systematic arrangement — in fact, the tout ermenible — reflect
great credit upon both author and publishers.
Resocouto clinico del comparto Hpeciale per le malatlie cutanee
delV Ospedale Maggiore di Milano, nel seiennio 1879-1884.
Memoria del D. Ambkogio Bertarelli, medico aiutante.
Milano: Tipografia Bortolotti di Dal Bono e C, 1885. Pp.
vii-159.
As its title indicates, this hook is a clinical report of theder-
matological wards of the Ospedale Maggiore, of Milan, for the
six years from 1879 to 1884 inclusive. We welcome it as an-
other evidence of the intellectual activity of Italy, and as a voice
from one of the largest hospitals in the world — one that was in
operation before this country was discovered.
Unlike many hospital reports, it is not a mere collection of
statistics, but resembles rather a series of clinical lectures upon
selected and more or less uncommon cases that have come under
the writer's notice. About thirty diseases of the skin are treated
of, illustrated by cases, and discussed in regard to their a'tiology,
pathology, diagnosis, and treatment. The histories of many of
the cases will well repay perusal, notably one of acute gangrene
of the skin from softening of the brain. Much space is devoted
to the consideration of eczema, lupus, and the parasitic dis-
eases.
The author is an enthusiastic disciple of Hebra. His views
are, nevertheless, not limited by the horizon of the Vienna
school, but are catholic in scope. We notice that in his thera-
peutics he has given fair trial to the methods of the representa-
tive men of all nations, and his deductions from these trials
enhance the value of the work. The book is of value as an
exposition of the state of dermatology in Italy at the present
time, and we can only regret that Dr. Bertarelli has stopped
short of giving us a complete treatise upon the diseases of the
skin as seen in his country.
BOOKS AND PAMPHLETS RECEIVED.
Gout, and its Relations to Diseases of the Liver and Kid-
neys. By Robson Roose, M. D., Fellow of the Royal College
of Physicians in Edinburgh. London : H. K. Lewis, 1885. Pp.
xii- 158.
Manual of the Antiseptic Treatment of Wounds. For Stu-
dents and Practitioners. By W. Watson Cheyne, M. B.,
F. R. C. S., Assistant Surgeon to King's College Hospital, etc.
With Illustrations. New York: J. H. Vail & Co., 1885. Pp.
xiii- 151.
L'Annee medicale (septieme annee), 1884. Resume des
progres realises dans les sciences medicales. Public sous la
direction du Dr. Bourneville, Medicin de l'hospice de Bieetre,
Redacteur en chef du "Progres medical." Paris: E. Plon,
Nourrit et Cie., 1885. Pp. viii-409.
Resoconto clinico del comparto speciale per le malattie cuta-
nee dell' Ospedale Maggiore di Milano, nel seiennio 1879-1884.
Memoria del D. Ambrogio Bertarelli, medico aiutante. Milano:
Tipografia Bortolotti di Dal Bono e C, 1885. Pp. vii-159.
A Manual for Hospital Nurses and Others engaged in at-
tending on the Sick. By Edward J. Domville, L. R. C. P. Lond.,
etc. Fifth Edition. Philadelphia: P. Blakiston, Son & Co.,
1885. Pp. 96. [Price, 75c]
The Pre-albuminuric Stage of Chronic Bright's Disease. By
Charles W. Purdy, M. D., etc. Chicago : Clark & Longley, 1885.
Pp. 35.
Poliambulanza delle speciality medico-chirurgiche, premiata
con medaglia d' argento all' Esposizione di Torino. II primo
anno di vita (1 Ottobre, 1883—30 Settembre, 1884).
July 25, 1885.]
LEADING ARTICLES.
101
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Poster, M. D.
NEW YORK, SATURDAY, JULY 25, 1885.
THE INTERNATIONAL MEDICAL CONGRESS.
So far as our information goes at the time we go to press,
the week has been comparatively barren of striking incidents
growing out of the International Medical Congress difficulty.
We have no knowledge of further concerted action in the way
of resolutions of disapproval and withdrawal, but individuals
have in a number of instances publicly declared themselves in
accord with the action taken in Philadelphia, Boston, Balti-
more, and Washington, and at the same time expressed their
intention not to take part in the Congress as at present sought
to be organized. It is worthy of note that not a few of these
gentlemen are residents of the West.
The inglorious part played by the New Orleans meeting of
the American Medical Association continues to be the subject
of comment. We have received a number of private commu-
nications approving of the position we took in our issue of the
11th inst., in which we explicitly fixed the responsibility for
the present disgraceful state of affairs upon the association —
not merely finding fault with the fortuitous indiscretion of the
New Orleans meeting, but tracing the possibility of that action
to the debased condition of the association itself. Many of our
contemporaries are taking the same view of the matter, and
some of them contain very pointed expressions. The "Medi-
cal Record " says that we have shown the association to be "a
useless and mischief-making body." It precedes this statement
with the remark that we were " at first a little non-committal,
not to say strabismic," in our views; but this we take in the
Pickwickian sense which is occasionally to be discerned be-
tween the "Record's" lines, and are content with its thor-
ough approval of the position that it finally discovers us to
hold.
The " Medical News " says : " The men who are engaged in
original research, and who are best known as those who are
contributing to the honor and dignity of American medicine by
their writings and teachings, are not usually active in medical
politics or in the supervision of their medical brethren, nor are
they given to log-rolling and striving for office. For the past ten
years these men have been becoming dissatisfied with the tone
of the American Medical Association, and, while many of them
have not formally severed their connection with it, they have
nevertbeless ceased to attend its meetings."
The " Maryland Medical Journal " uses the most forcible
language to express its condemnation of the American Medical
Association, as will be seen by its editorial of last week, which
we reproduce elsewhere in this issue. The " Canada Medical
and Surgical Journal " alludes to the withdrawals, and adds :
" When we ask why they take this serious step, we learn that
tbey have, in the first place, a deep distrust of the American
Medical Association as an organization which could satisfac-
torily carry out such an undertaking."
Speaking of the general subject, the " Medical Times and
Gazette," of London, says: "There is a very unfortunate dis-
cussion going on at present in professional circles in America,
which, it is quite possible, may turn out disastrously for the
International Medical Congress which it has been decided to
hold at Washington in 1887. It will be remembered that a
small Committee of the American Medical Association was
nominated by the executive of the Copenhagen Congress, with
full power to add to their number, and to act on behalf of their
professional brethren. Carrying out their mission, they chose
as colleagues twenty-eight leading American practitioners, espe-
cially selected on account of their standing in the profession,
and drew up the programme which has already been published.
Subsequently, when the Committee reported to the meeting of
the American Medical Association at New Orleans, exception
was taken to their proceedings on the plea that they had ex-
ceeded their powers, and had no commission to act on behalf of
the association. The jealousies that had been roused among
those who had been passed over in the co-optative selection
were worked upon by two or three pushing wire-pullers, and,
in the end, resolutions were passed, revising the work of the
Committee, and substituting a Committee of thirty-eight men
selected from the different States and Territories for those
added to their number by the original Committee. At a subse-
quent meeting, the results of which we are daily expecting to
hear, the subject was again to come under consideration, and
we learn that it was the intention of all the leading practition-
ers in the States to withdraw from the Congress, if the decisions-
of the original Committee were not treated with more respect.
We sincerely hope that the profession in America will strenu-
ously support their recognized leaders; otherwise they will
make an exhibition of themselves to the world, and, besides im-
periling the future success of those international gatherings
which have hitherto been conducted with so much harmony,
will distinctly lower the respect in which the profession is held
throughout the world."
MINOR PARAGRAPHS.
"DANIEL'S TEXAS MEDICAL JOURNAL."
" Daniel's Texas Medical Journal " is now, to use its own
expression, launched. We lately took occasion to commend Dr.
Daniel's undertaking, and he now reciprocates by mentioning
this journal a number of times in his first issue. To be sure,
much of what he puts forward as quotations from our columns
never appeared in them, but we have grown quite accustomed
to being misquoted and to having our meaning perverted. It
seems that this journal was not the only one to notice Dr. Dan-
iel's journal in advance of its appearance, for he quotes the fol-
lowing— and we envy the state of mind that enables him to re-
produce it with apparent satisfaction — from the "Denver Medi-
cal Journal " : " Dr. F. E. Daniel, of Austin, Texas, sends us the
prospectus of 'Daniel's Texas Medical Journal.' To those <>t'
our readers who were lovers of the editorial writings of the
much lamented Gaillard we commend Dr. Daniel as the coming
102
MINOR PA
EAORAPHS.
[N. Y. Mkd. Jocb.,
' Mephistopheles of medical journalism.' At least we will ven-
ture to so christen the baby." We wonder if Dr. Daniel has
ever read Faust, and we wonder also if the " Denver Medical
Journal " realized with what sort of character it coupled the
name of a man who was utterly free from guile.
VIVISECTION IN ENGLAND.
We regret to learn that Mr. Lawson Tait has again thought
fit to cast the weight of his influence publicly in aid of the anti-
vivisection mania in England. We do not question bis entire
conscientiousness in the matter, and it is even conceivable that
he might make a good argument in favor of the proposition
"that vivisection is not only useless in solving riddles such as
we have to deal with, but that it is absolutely misleading." A
forcible argument could perhaps be made in support of that
position, but certainly not one that would prove convincing to
the present generation of medical men, who owe almost all that
they possess of real physiological knowledge to the practice
which Mr. Tait condemns.
THE PROPOSED TEACHING OF HYGIE.VE AT WEST POINT.
It seems to us that a most excellent suggestion has been
made in the recent report of the Board of Visitors of the Mili-
tary Academy, namely, that the officers of the medical corps od
duty at the post should give lectures on hygiene to the senior
class of cadets. Not only is it indisputable that a knowledge of
the principles of hygiene by the line officers of the army is in
the highest degree desirable, but it is also scarcely less certain
that for the medical officers in question to devote a portion of
their time to teaching those principles would be both agreeable
and profitable to them as individuals and as officers. Moreover,
in the course of a very few years the whole medical corps
would find its routine duties much facilitated by the increased
readiness with which officers in command of posts would grasp
the purport and appreciate the importance of the hygienic
measures recommended by the medical officers from time to
time. We trust, therefore, that the board's suggestion will
meet with favor at Washington.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Health Department for the following
statement of cases and deaths reported during the two weeks
ending July 21, 1885 :
DISEASES.
Week ending July 14.
Week ending July 21,
Cases.
Deaths.
Cases.
Deaths.
Tvphus
1
0
1
0
Tvphoid fever
9
2
10
2
Scarlet fever
31
9
40
14
Cerebro-spinal meningitis ....
4
3
4
3
Measles
55
10
48
8
55
24
59
23
2
1
2
0
Small-pox is reported as prevailing in the town of Scotland,
in Dakota, twenty-five cases having been discovered last Sun-
day.
Anthrax in Louisiana. — Anthrax is reported to be prevail-
ing extensively among cattle in the region of New Iberia, La.
The International Sanitary Conference and the Disin-
fection of Rags. — One of the incidents in a controversy that
has been going on for some months between certain sanitary
officials and the importers of rags was the suggestion that a
report of the proceedings of the recent International Sanitary
Conference held in Rome, which appeared in a Philadelphia
medical journal, contained an interpolation by the correspondent
of the journal in question, in the following clause : '' Disinfection
of merchandise and of the mails is unnecessary (steam under
pressure is the only reliable agent for the disinfection of rags —
les chiffons en gros).'1'' This suggestion having been urged in
the "New York Times," the American delegate to the Confer-
ence, Dr. George M. Sternberg, of the army, wrote to that
paper denying the truth of the charge and affirming the accu-
racy of the account given in the Philadelphia journal. The
" Times " now returns to the matter and publishes the follow-
ing remarkable statement: 11 A gentleman of this city, who is
interested in the importation of paper stock, wrote to Dr. Koch,
at Berlin, for definite information on this point, and yesterday
he received a cablegram stating that no such words as those
quoted in parentheses appear in the report of the committee."
The American Laryngological Association.— At the re-
cent annual meeting, held in Detroit, Dr. Wilhelm Meyer, the
distinguished professor of laryngology in the University of Co-
penhagen, and president of the combined laryngological and
otological sections of the last International Medical Congress,
was unanimously elected a corresponding fellow of the asso-
ciation. Dr. H. Clinton McSherry, of Baltimore, and Dr.
Charles H. Knight, of New York, were elected to active fel-
lowship.
Professor Tyndall's Gift to American Colleges.— The
" British Medical Journal " states that the proceeds of Professor
Tyndall's lectures in the United States in 1872, which, with the
accumulated interest, now amount to $32,400, are to be divided
equally between Columbia College, Harvard University, and the
University of Pennsylvania.
The Medico-Chirurgical College of Philadelphia. — We
learn that Dr. F. Le Sieur Weir has severed his connection with
the college.
The Death of Dr. Thomas E. Burtsell, of New York, took
place on Thursday of last week. The deceased was a graduate
of the Medical Department of the University of the City of New
York, in the class of 1844.
The Death of Surgeon Joseph H. BilL of the Army, took
place in Yonkers on Tuesday last. He was a native of Penn-
sylvania, and was appointed first lieutenant and assistant sur-
geon April 13, 1800. March 13. 1865, he received the brevet
ranks of major and of lieutenant-colonel for faithful and meri-
torious service during the war. April 13, 1865, he was com-
missioned captain and assistant surgeon, and July 28, 1866,
major and surgeon. His death is said to have been due to
Bright's disease.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from July 12, 1885, to July 18, 1885:
Voli.um, E. P., Lieutenant Colonel and Surgeon. To be relieved
from duty in Department of the East on the expiration of his
present leave of absence and to report to commanding gen-
eral, Department of the Platte, for assignment to duty as
attending surgeon at the headquarters of that department.
S. O. 159, A. G. O., July 14, 1885.
Middleton, J. V. D., Major and Surgeon. Leave of absence
extended fifteen days. S. O. 159, A. G. O., July 14, 1885.
Brown, J. M., Major and Surgeon, Captain Clarence Ewen,
Assistant Surgeon, . Captain A. W. Taylor, Assistant Sur-
geon, and First Lieutenant W. C. Borden, Assistant Surgeon.
Ordered to prepare for field service. S. O. 64, Department
of the Platte, July 9, 1885.
July 25, 1885.]
PROCEEDINGS OF SOCIETIES.
103
Gray, TV. W., Captain and Assistant Surgeon. Relieved from
duty at Fort Barrancas, Fla., and ordered for duty at Fort
Columbus, New York Harbor. S. 0. 147, Department of
the East, July 13, 1885.
Everts, Edward, First Lieutenant and Assistant Surgeon. Or-
dered for duty as Post Surgeon, Fort McDermit, Nevada. S.
(). 68, Department of California, July 11, 1885.
Poliiemus, A. S., First Lieutenant and Assistant Surgeon. Or-
dered for duty as Post Surgeon, Benicia Barracks, California.
S. 0. 68, Department of California, July 11, 1885.
Winn-e, C. K., Captain and Assistant Surgeon. Ordered for
duty at Benicia Arsenal, California. S. O. 68, Department
of California, July 11, 1885.
Edie, G. L., and C. S. Black, First Lieutenants and Assistant
Surgeons. Ordered for duty with troops en route to De-
partment of Missouri. S. O. 78, Department of Texas, July
10, 1885.
Naval Intelligence. — Official List of Changes in the Medi-
cal Corps of the United States Navy during the week ending
July 18, 1885.
Owens, Thomas, Assistant Surgeon. Granted sick leave for one
month. July 14, 1885.
Society Meetings for the Coming Week :
Monday, July 27th : Boston Society for Medical Improvement.
Tuesday, July 28th : Medical Society of the County of Putnam,
N. Y. (annual).
Wednesday, July 29th : Auburn, N. Y., City Medical Associa-
tion; Gloucester County, N. J., Medical Society (quarterly);
Berkshire District (Pittsfield) and Middlesex North District
(Lowell), Mass., Medical Societies.
Thursday, July 30th: Cumberland County, Me., Medical So-
ciety (Portland).
Proceedings of Soeutus.
AMERICAN OPIITHALMOLOGICAL SOCIETY.
Twenty-first Annual Session, held at the Pequot House, New
London, Conn., Wednesday and Thursday, July
15 and 16, 1885.
Wednesday's Proceedings. — Morning Session.
The meeting was called to order by the president, Dr.
William F. Norris, of Philadelphia.
Operation for the Removal of a Dislocated Crystalline
Lens. — Dr. C. R. Agnew, of New York, related the steps of the
operation as follows : The pupil was dilated, and the patient was
then etherized and cocaine was applied. The eye was secured
with fixation forceps. An instrument resembling a two-pronged
fork, which was termed a bident, was introduced into the vitre-
ous chamber behind the dislocated lens, pressing it forward.
Section was then made and the lens removed. The eye was
dressed with absorbent cotton and a black silk bandage. Anti-
septic solutions were used, and a fonr-per-cent. solution of co-
caine was applied twice a day. The eye recovered without any
unpleasant symptoms. The speaker did not claim that all dis-
located lenses should be removed, but this instrument facilitated
the operation when it was required.
Extraction of a Dislocated Lens.— Dr. David Webster, of
New York, reported the case of a patient who received a blow
on the right eye. This was immediately followed by loss of
sight. Examination showed that the lens was dislocated. No
treatment was recommended at that time. Some months later,
pain suddenly appeared in the injured eye. The lens was found
to be cataractous and incarcerated in the pupil. Cocaine was
applied, but did not relieve the pain. Atropine relieved the
pain. Later the lens became loose and was found in the vitre-
ous. The tension was normal. It was decided to remove the
lens. The bident was passed back of the lens, pressing it for-
ward. The incision in the cornea was then made and the lens
removed with a spoon. The eye was dressed with absorbent
cotton, and recovered without complication.
Dr. II. Knapp thought that in these cases there was not
much difficulty in removing the lens, which could often be ac-
complished with the loss of very little vitreous, but the danger
came in afterward from inflammatory complications; and where
the sight was lost he thought it better to enucleate the eye at
once and tbus lessen the dangers of inflammation.
Dr. Williams, of Cincinnati, agreed with Dr. Knapp that
enucleation was the best procedure.
Dr. Agnew thought that the bident might also be useful in
the removal of foreign bodies from the interior of the eye. He
did not acquiesce in the view that enucleation was a simple
operation. He regarded it as a serious mutilation.
Dr. C. H. Williams, of Boston, thought that there was an-
other alternative than those mentioned, and that was eviscera-
tion of the eye, and closure of the anterior opening with sutures.
He thought this better than enucleation, and it gave a better
stump for the artificial eye.
Extraction of the Lens in its Capsule.— Dr. D. B. St. John
Roosa, of New York, said that for the past three years he had
been in the habit of removing the lens in its capsule, in a large
proportion of cases without iridectomy. The section was made
as usual, but large. After puncture and counter-puncture were
made, the knife was turned on its back so that it rested on the
iris. It was then moved up and down two or three times until
the lens was seen to move; then the section was completed, and
the lens could usually be removed without loss of vitreous.
Sometimes after the operation the iris was rolled under, but in
many cases the pupil was circular. Dr. Roosa had performed
the operation between thirty and forty times, and was satisfied
with his success.
Sub-conjunctival Luxation of the Lens.— Dr. George C.
Harlan, of Philadelphia, reported two cases. In the first case
no operation was recommended, as vision was good. In the
second case the lens was removed. In those exceptional cases
in which vision remained, the operator should think twice be-
fore resorting to removal.
Dislocation of the Lens under Tenon's Capsule.— Dr. 0.
F. Wadsworth, of Boston, reported a case in which the eye
had been injured two weeks before the patient came under ob-
servation. There was loss of sight, pain about the eye and irri-
tation of the other eye, the cornea was hazy, and there was
blood in the anterior chamber. The eye was enucleated, and it
was found that the lens was beneath Tenon's capsule, and that
it was held in this position by inflammatory tissue.
The Treatment of Purulent Conjunctivitis.— Dr. J. A.
Andrews, of New York, read a paper on this subject in which
he said that the treatment was based upon the belief that the
contagious element was of the micrococcus variety. He related
a case in which he had secured an inoculation of the seventh
generation of a pure cultivation of a gonococcus. This was the
first case inoculated with the gonococcus. Ho exhibited an
instrument which ho had devised to wash out the conjunctival
cul-de-sac. It consisted of an eye speculum with hollow arms
through which fluid might be passed. He had found bichloride-
of-mercury solution (1 to 10,000) serviceable, but apt to irritate.
A six-per-cent. solution of boric acid was also found efficient.
104
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Joi n.,
A two-per-cent. solution of carbolic acid was useful, as it in-
hibited the movements of the white corpuscles. Irrigation should
be maintained for ten minutes in order to remove all secretion.
Nitrate-of-silver solution (two to twelve per cent.) was then
used, and an antiseptic dressing was next applied. This con-
sisted of vaseline and boric acid or carbolic acid; but he laid
especial stress upon the importance of maintaining irrigation of
the conjunctiva by means of the instrument referred to.
Abscess of both Frontal Sinuses.— Dr. Charles S. Bull, of
New York, related a case in which the patient had been hit on
the forehead fourteen years previously with a piece of wood.
This produced a fracture of both nasal bones and deviation of
the septum. In seven weeks the wound had closed. Ten years
after the accident a swelling was noted at the upper inner angle
of the right orbit which could be made to disappear by pressure.
There was complete ptosis. An incision was made into the
swelling just beneath the orbital margin and a large quantity of
pus escaped (two or three ounces). The cavity was washed
with a five-per-cent. solution of carbolic acid. The septum be-
tween the two frontal sinuses was absorbed and both sinuses
were converted into large cavities. The entire ethmoid bone
was an immense cavity, the bony suture being absorbed. A
number of osteophites were removed and a drainage-tube was
introduced. The patient was discharged six weeks after the
operation and recovered completely. The ptosis disappeared
and the eye was restored to the normal plane.
Dr. Knapp recommended the substitution of a silver tube
for the rubber drainage-tube usually employed.
Bony Tumor of the Orbit.— Dr. B. E. Fryer, of Kansas City,
Mo., related the case of a boy six years of age who came under
observation in April, 1885. There was swelling of the left orbit,
which included the whole line of the superciliary ridge. It was
quite hard. The boy had been struck with a piece of wood. It
was decided to remove the tumor. This was done, and, on
examination, it proved to be a cyst within which was a small
piece of wood. This was inclosed in bone on all sides. The
edges of the wound were brought together and healing resulted
without complication.
Sarcoma of the Orbit in a Child.— Dr. W. H. Carmalt, of
New Haven, Conn., reported the case of a child of ten years of
age from whom he removed a small growth from the upper lid.
Six weeks later the growth had returned. An exploratory
operation was done, and it was found that the growth extended
into the orbit, and that it was impossible to remove it entirely.
It was therefore decided not to complete the operation. The
child had since died, and the tumor proved to be a rapidly
growing sarcoma. He thought that, if in young children the
tumor appeared to be quickly recurrent and not easily isolated,
no operative interference should be attempted.
Dr. Kipp, of Newark, thought that in many cases these
tumors of the orbit were not primary, but secondary, and that
the primary tumor might be in such a position as not to attract
attention.
Dr. Harlan, of Philadelphia, reported several instances of
nflammatory exudations in the orbit simulating tumors, and
illustrating the importance of exercising great care in diagnosis.
Some of the Results obtained in the Compilation of
1,000 Cases of Refraction.— Dr. E. E. Holt, of Portland, Me^
had been in the habit of recording all the measurements con-
nected with the prescribing of glasses. As a result, he had
found, in 1,000 cases thus recorded, the average distance be-
tween the centers of the pupils of the human eye to be about
60 mm. The average of other measurements was given, and
the importance of the physician determining and designating
them, and then seeing that they were carried out, was dwelt
upon.
Rapidly Progressive Myopia checked by Section of the
External Rectus.— Dr. Harlan related the case of a boy of
sixteen in whom myopia was progressing rapidly. The exter-
nal rectus was divided seven years ago. The internal rectus
was also excised by the use of prisms. Since then there has
been no increase of the myopia.
Progressive Astigmatism.— Dr. Samuel Theobald, of Bal-
timore, related three cases of this affection.
Afternoon Session.
Hypermetropic Refraction passing into Myopic Re-
fraction.— Dr. S. D. Risley, of Philadelphia, had on previous
occasions called attention to five cases of a similar kiDd, and the
object of his paper was simply to report six additional cases
seen within the past year.
The Demonstration of Refraction and Accommodation.
— An apparatus for this purpose was exhibited by Dr. Luoien
Howe, of Buffalo, N. Y. It consisted of two bands of thin
metal bent in such a manner as to represent the outlines of a
double convex lens, and passing through it were two jointed
rods representing the raj's of light ordinarily figured as pass-
ing through such a lens and joining at its focus. The flexible
bands were attached to each other above and below, so that,
by approaching or separating the sides, they could be made to
show less or greater convexity. The rods representing the rays
of light were jointed near the center in such a way that while
the two halves could be placed in such a direction as to show
the light as entering parallel to the axis of the lens, the other
two portions could be beat to a point to show the convergence
of rays at the focus. By alteration in the position of these
rods, and also in the forms of the bands representing the lens,
all the different variations of the laws of refraction and the
changes in accommodation could be demonstrated to a class.
Two Cases of Unilateral Temporal Hemianopsia. — Dr.
C. S. Bull read a paper with this title. [It will be published
in full in a future number of the journal.]
Penetration of the Eyeball with Scissors in the Operation
for Strabismus. — Dr. H. Derby, of Boston, reported two cases,
the first of which was that of a young man on whom an operation
for strabismus had been attempted. The surgeon inadvertently
picked up a pair of sharp-pointed scissors. The point of the
scissors suddenly penetrated the eyeball, and a portion of vitre-
ous, equal in size to a cherry-stone, escaped. The operation
was abandoned, and Dr. Derby was called to see the case. The
eye was bandaged and the patient put to bed. Several attacks
of inflammation supervened, but the patient was discharged on
the forty-first day with V = TV
In the second case the scissors also entered the sclerotic, but,
after a somewhat tedious convalescence, the wound was found
closed on the twenty-first day with vision as good as before the
operation.
Dr. Knapp stated that he had done three thousand squint
operations, and in three cases he had punctured the sclerotic.
He, however, completed the division of the muscle, and the pa-
tients recovered as readily as from an uncomplicated operation.
Dr. Mittendorf thought that in case the accident happened
the division of the muscle should be completed.
Dr. E. Williams reported a case in which he had punctured
the eye. The patient recovered without difficulty.
Strabismus ; its Correction when Excessive and in High
Degrees of Amblyopia.— Dr. E. E. Holt read a paper with
this title, in which he said that he had employed advancement
of the weakened, attenuated muscle in connection with tenoto-
my in certain cases of squint, and after tenotomy alone had
failed to correct the deviation. He also exhibited an apparatus
that he had devised for showing the associated and accommoda-
July 25, 1S85.J
PROCEEDINGS OF SOCIETIES.
105
tive movements of the eyes and the effects of tenotomy and ad-
vancement of the muscle in correcting squint.
Dr. Kipp had at one time employed advancement, hut he
had given it up because it was difficult to graduate the result.
The Treatment of Strabismus Interims.— Dr. W. W.
Seely, of Cincinnati, read a paper with this title, and from
which lie made the following deductions: 1. That, with out-
present knowledge, routine operative interference is wrong. 2.
That to thoroughly correct the deviation in young children by
operative interference is extremely liable to subject them in
after life to insufficiency or external squint. 3. That a later
period of life, if anything, favors better results from operative
interference.
Dr. Knapp considered advancement a dangerous operation.
He had always been able to correct the deviation by two or
three tenotomies, and, if necessary, by stitching the eye to the
commisure.
Dr. Theobald indorsed Dr. Knapp's views in reference to
advaucement. He was surprised at the conclusions of Dr.
Seely. Squint operations in his hands had been very satisfac-
tory: If postponed, they were likely to prove unsatisfactory on
account of the amblyopia which was liable to develop.
Dr. 0. F. Wadsworth had convinced himself that amblyo-
pia from squint did not occur. The ability of the patient to use
the vision which he had seemed to be lost by a continuance of
the squint, but it might be recovered by practice.
Ectropion of Both Lids ; Blepharoplasty by the Italian
Method.— Dr. R. H. Derby, of New York, reported a case in
which the displacement of the lids was the result of cicatricial
tissue from a severe and extensive burn of the face. The lids
were loosened from their attachments, and the new lids were
formed from flaps raised from the arm. The aim was bound to
the head with water-glass plaster, and the pedicle was not
divided until union had taken place.
Plastic Operations without Pedicles. — Dr. B. Joy Jef-
fries, of Boston, read a paper with this title, in which he sug-
gested the use of the prepuce from the circumcision of Jewish
children for operations about the eyes. He also suggested that
in plastic operations the desired result might be obtained with-
out the use of a flap by employing carbolized-oil dressings to
retard healing.
( To be concluded.)
AMERICAN OTOLOGICAL SOCIETY.
Eighteenth Annual Meeting, held in New London, Conn.,
Tuesday, July 1^, 1885.
The President, Dr. C. H. Burnett, of Philadelphia, in the Chair.
Dr. Charles J. Kipp, of Newark, showed a copy of Retzius's
work on the "Anatomy of the Organ of Hearing in Vertebrate
Animals."
The President reported the deaths of two members during
the year — Dr. John H. Dix, of Boston, and Dr. Edward T. Ely,
of New York.
Inflammation of the Attic of the Tympanum.— Dr. Sam-
uel Sexton, of New York, read a paper in which he first re-
ferred to the importance of inflammation arising in the attic as
compared with that arising in the atrium. The atticus tympanicus
was described as that portion of the tympanum lying above a
plane extending transversely from the prominence on the inner
wall, formed by the external semicircular and facial canals, to
the auditory plate on the outside. Beneath this plane lay the
atrium tympanicum. Over the attic arches were the tegmen,
which also covered the antrum, the petro-mastoid canal, a vary-
ing number of cellules, and the Eustachian tube. The attic com-
municated freely with the antrum by means of the petro-mastoid
canal of Sappey. The mastoid antrum lay behind and to the
outer side of the attic, in the spongy substance of the mastoid.
It was usually larger than the attic, and, as a rule, extended
downward among the cellules of the mastoid process, giving off
frequently a small passage, communicating with the cellules
overlying the external auditory meatus. The attic was divided
below into two compartments, the inner being the larger, by the
incus and malleus, the cord, ligaments, etc., which formed a
partial antero-posterior partition. These compartments com-
municated freely with each other above, with the atrium below,
with the Eustachian tube in front, and with the antrum behind.
The outer compartment was wedge-shaped, larger above, and
shut in below by the close approximation of the large ossicles to
the auditory plate, except anteriorly and posteriorly, where two
small openings allowed of drainage into the atrium below. The
inner compartment also communicated with the atrium by an
elliptical opening surrounded on the inner side by the facial
canal and on the outer by the large ossicles, the cord, ligaments,
etc. All these cavities were lined throughout with mucous
membrane. Acute inflammation of the attic might result from
catarrh of the head, the exanthemata, or the entrance of fluids
propelled along the Eustachian tube in bathing or from the
use of the nasal douche. Irritating fluids seemed always to be
better borne in the lower than in the upper part of the tym-
panum. Inflammation of the attic might occur in connection
with, or be independent of, inflammation of the atrium. It was
the more serious from the fact that swelling of the mucous mem-
brane clogged the outlets and prevented drainage. In such cases
the membrana flaccida was red, the vascular turgescence extend-
ing above into the external auditory canal and sometimes down-
ward about the short process of the mallet. Should the disease
progress further, the inflammation might extend beneath the
margo tympanicus of the auditory plate, and be followed by
effusion of serum and blood, which pressed away the membrana
flaccida and the integument of the canal, producing a bulging
sac so great sometimes as to entirely conceal the membrana
tympani, and it might entirely fill the canal and present at the
lumen as a purplish tumor. Periostitis of the surrounding parts
might occur and extend along the surfaces of the canal, and
inflammation might spread to the atrium ; hut, so long as this
did not occur and the membrana tympani was unaffected, there
might be little deafness, though autophonia might be present.
In nearly all these cases inflammation in some degree extended
into the antrum and mastoid cellules, or those overlying the
external auditory canal, or those situated in the tegmen. If the
escape of secretions into the atrium or Eustachian tube was
prevented, the case was more severe and extension to the cranial
cavity more to be feared.
The proper treatment was to effect drainage and employ
such constitutional remedies as tended to check the inflamma-
tion and prevent the formation of pus, such as aconite, calx sul-
phurata, etc. It was impossible to make an accurate differential
diagnosis between the pains of pachymeningitis and the neuralgic
pains of otitis media. The surgeon should therefore be cautious
about trephining the mastoid where pain was the only symptom.
After pachymeningitis had set in, it was manifestly useless to
perforin this operation.
Dr. D. B. St. John Roosa, of New York, thought that the
remedies mentioned, mercury and calcium sulphide, were not in
common use in the way recommended by the author. He had
used them without any favorable effect. A warm room, a
good nurse, taking care of the bowels, and local measures were
the most important. The internal treatment should be expect-
ant. He would like Dr. Sexton to describe a case indicating
the manner in which he would use these remedies.
Dr. Sexton stated that the particular point of his paper was
106
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jock.,
in regard to the inflammation of the attic, and not the use of
remedies. The moment there were symptoms of puruleney he
administered the calcium sulphide.
Dr. J. A. Andrews, of New York, referred to a case in
which the inflammation was most intense in the upper part of
the tympanic cavity, and a perforation was estahlished between
the mastoid antrum and the external auditory canal. There
was a great deal of swelling of the external auditory canal.
Examination under ether showed a fluctuating swelling in t lie
superior-posterior part of the canal, which was incised, and
considerable blood and pus escaped.
Dr. 0. D. Pomekoy, of New York, asked if Dr. Sexton be-
lieved that mercury relieved the pain.
Dr. Sexton had never used it exclusively to relieve pain, and
had not recommended it for that purpose. For the relief of
pain he would recommend the use of aconite and pulsatilla, the
latter especially.
Dr. C. R. Agnew, of New York, said that when there was
acute otitis media it was desirable to cut it short as soon as pos-
sible. If a patient came to him with the symptoms of begin-
ning otitis media lie would give him fifteen grains of calomel
and order a Turkish bath if that was accessible. With children
there was always a certain amount of indefiniteness in the
symptoms. He asked Dr. Sexton what he would do in a case
of acute otitis media catarrhalis in an infant six months old.
Dr. Sexton would examine the history. If there was an
accumulation he would let it out. In the majority of cases at
this age the membrane had already ruptured when the case
came under observation. If there was suppuration, he would
give calcium sulphide. If there was simply catarrh, he would
give mercury.
Dr. Kipp spoke of the value of inflation of the middle ear.
This relieved the pain. Where there was protrusion in front of
the membrane, incision gave relief.
Dr. Theobald, of Baltimore, had found the instillation of a
warm solution of atropine of great service, a solution of the
strength of four grains to the ounce. He had used pyrophos-
phate of sodium in fifteen-grain doses in inflammation of the
middle ear with threatened mastoid implication, aud was con-
vinced that it was of real value.
Dr. C. J. Blake, of Boston, referred to a reduplication of the
mucous membrane in the upper portion of the tympanic cavity,
which he had found in fifteen or twenty per cent, of two hun-
dred specimens examined. This served to separate the upper
portion of the tympanic cavity from the lower. It became an
important element in inflammation of this part, and might tend
to retain secretions.
Dr. Sexton had used mercury and sulphide of calcium for
the last ten years in many cases, and was convinced that they
were beneficial in a certain number.
The Treatment of Chronic Otitis Media.— Dr. W. W.
Seelt, of Cincinnati, read a paper with this title, which closed
with the following conclusions: 1. Only long observation (often
lasting over months) in each case could determine whether
treatment should be continuous (daily) or interrupted — i. e.,
perhaps daily for a week, followed by an interruption of some
weeks or months. 2. Only experience in each case could inform
us whether treatment was to be entirely directed to the middle
ear, or entirely to the naso-pharynx, or combined against both.
3. Only experience in each case could inform us whether injec-
tions into the cavitas tympani were called for. Under this head
it was stated that direct medication, either of the middle ear or
the naso-pharynx, as routine treatment, was unwise till simple
inflation had failed. 4. Mechanical dilatation of the tubes was
rarely necessary or advisable; only in extremely dry states of
the tube was dilatation followed by much success. 5. Hearing-
tests were not reliable, and hence patients with great deafness,
great loss of bone conduction, etc., should not be sent away til)
the test by trial had been gone through with. 6. Simple in-
flation failing, the greatest attention should be given to the
naso-pharynx, even though it was apparently in a fair condition.
7. Syringing, douching, and swabbing the naso-pharynx should
be abandoned.
The Relations between Chronic Catarrhal Otitis Media
and Chronic Rhinitis. — The President read a paper in which
he stated that he had found a constant causal relation between
chronic catarrh of the middle ear and chronic rhinitis and rhino-
pharyngitis. The latter was chiefly of the hypertrophic form.
The atrophic form constituted about fourteen and a half per
cent. The appearances of the membrana tympani in the first
class were very diversified — so much so as to preclude a deter-
mination of the state of the middle ear and hearing from them
alone. In the atrophic class, the symptoms presented by the
membrana tympani were more uniform and consistent, and the
surgeon was able to determine from them more precisely con-
cerning the aural disease. Yet, on the whole, the appearances
of the drum, taken by themselves, could not aid greatly in the
diagnosis of chronic aural catarrh. Tinnitus aurium was, as a
rule, more marked in the atrophic class than in the hypertrophic,
There was also a greater patency of the Eustachian tube in the
atrophic forms than in the hypertrophic. It was most relieved
by treatment of the nares and naso-pharynx. The treatment
in the first class should be by cleansing and astringent sprays,
with applications of preparations of iodine never stronger than
half-and-half. Nitrate of silver was not to be used at all in
hypertrophic rhinitis. In the atrophic form, the treatment was
cleansing, the removal of inspissations if they occurred, and the
application of stimulant sprays, preferably of nitrate of silver,
not stronger than four grains to the ounce of water. Where
the hypertrophies had become dense and large, requiring surgi-
cal removal, the case should pass into the hands of the rhinolo-
gist. A word of caution was given in regard to the use of the
galvanic cautery in the nares, since, like the nasal douche, it
might lead to inflammation in the naso-pharynx and middle ear.
Dr. Agnew thought there was an anatomical objection to the
use of salves, and that was the impossibility of applying them
to the whole of the diseased surface by means of Bowman's
probe. He was not prepared to accept the law that the nasal
syringe should be abandoned. He thought more stress should
have been laid on hygiene, which was the most important ele-
ment in the treatment.
Dr. Roosa also considered that the principal and only bene-
fit to be obtained in the majority of these cases was from proper
hygiene; it was not necessary to continue examinations very
long or repeat them very often to determine whether or not
relief might be expected. If there was diminished bone con-
duction, it was useless to go on and treat the patient.
Dr. H. Knapp, of New York, had employed in his own
person a salve of iodoform with vaseline with considerable
advantage.
Dr. Seely had had more satisfaction from salves than from
any other treatment. They remained longer in contact with
the affected part than solutions, thus giving a more decided
effect.
Afternoon Session.
Dr. Sexton presented a conversation tube for the aural in-
struction of deaf-mutes. By means of this tube the patient was
able to hear his own voice and compare it with the voice of his
teacher.
Professor Graham Bell called attention to the great num-
ber of children classed as deaf-mutes who, under proper edu-
cation, could be made simply hard-hearing members of society.
July 25, 1885.1
PROCEEDINGS
OF SOCIETIES.
107
A Case of Fatal Ear Disease beginning as a Circum-
scribed Inflammation of the External Auditory Canal.— Dr.
Kipp read the history of the case of a married woman, aged
twenty-eight years, who was first seen nine months hefore her
death. Since a confinement, four months hefore, she had suf-
fered occasionally with severe pain in and ahout the left ear.
There were swelling and redness of the posterior upper wall of
the external canal. There was no perforation and no otorrhoea.
Under the use of leeches, instillations of morphine, and infla-
tion of the middle ear, there was decided improvement in the
course of a month, when she passed from under observation.
Eight or nine months later the pain again appeared, shortly
after a confinement. Examination of the ear showed great
swelling of the external canal, but the tympanic membrane and
the middle ear appeared to be normal, and there was no tender-
ness over the mastoid. The patient recovered from this attack,
but the pain in the head continued, and she finally died. At the
autopsy there was found evidence of intense inflammation over
the entire exteut of the arachnoid and pia mater. There was a
collection of pus immediately over the posterior surface of the
petrous portion of the temporal bone. Pus was also found on
the pons Varolii. A small abscess was found in the anterior
part of the left lobe of the cerebellum, near its junction with
the pons. The mastoid cells were filled with pus. There was
only a thin exudation in the middle ear.
The President reported a case similar in many respects, in
which the patient died from what was diagnosticated as cere-
bral abscess, but no autopsy could be obtained.
Dr. E. E. Holt, of Portland, Me., reported the present con-
dition of a patient from whom teratoid tumors had been re-
moved two years ago, and in whom the disease had returned in
one year.
The Local Use of Cocaine and Brucine in Diseases of the
Ear. — The President read a paper in which he said that he had
used the sulphate and the hydrochlorate of cocaine to produce
anaesthesia in painful affections of the ear. Neither was effi-
cient when the pain was due to inflammation of the dense tis-
sues of the external auditory canal, nor when acute inflamma-
tion occurred in chronically thickened periosteal and mucous
tissues in the tympanic cavity. A four-per-cent. solution of the
hydrochlorate induced anaesthesia in congestion of the skin of
the fundus of the auditory canal and in the membrana flaccida
where the pain was not too intense and continuous. The solu-
tion was applied directly to the affected part, while the canal
was illuminated by the head-mirror. The anaesthesia of the
external auditory canal produced by cocaine was not profound
enough to permit of painless incision into it. He had also used
brucine in a five-per-cent. solution with success in producing
local anaesthesia.
Does Cocaine Hydrochlorate, while relieving the Pain
in Acute Otitis Media, prolong the Congestion?— Dr. Holt
read a paper with this title. This question had occurred to him
several times where he had used the remedy for the relief of
pain in the middle ear. He was satisfied that, while cocaine
relieved the pain, and for the time held the inflammation in
check, yet, after the effect of the remedy passed off, the inflam-
mation went on unaffected.
On the Desirability of adopting a Uniform Method of
expressing the Results of testing the Acuteness of Hear-
ing was the title of a paper read by Dr. Knapp, in which the
following method of record was suggested :
H = ||, normal hearing for a watch.
H = |§, normal hearing for the whispered voice.
H = normal hearing for conversational speech.
II = whisper or speech heard, hut not understood (quali-
tative perception of sound).
H 60' = O, voice not heard at all.
H = O, complete deafness for all sounds.
Q
H = — , a watch of 24" hearing distance heard on contact
24'
with ear.
Pr.
H — — , a watch of 24" hearing distance heard when
24
pressed on ear.
M
H = — , a watch of 24" hearing distance heard when ap-
24 »
plied to mastoid.
T
H = — , a watch of 24" hearing distance heard when ap-
24 6
plied to temple.
H — — , a watch of 24" hearing distance heard when ap-
24
plied to teeth.
H = — ', a watch of 24" hearing distance heard when ap-
24
plied to forehead (glabella).
V
H = , a watch of 24" hearing distance heard when ap-
24
plied to vertex.
II = — — , a watch of 24" hearing distance heard when ap-
24' b
plied anywhere (unique).
To indicate that the watch was not heard at the places
C M
enumerated, the following were used : H — = 0, H — = 0,
etc. II = O would mean that bone-conduction for the
24
watch was lost.
Presbykusis. — In a paper with this title, Dr. Roosa applied
the term to the failure of hearing incident to old age and not
dependent upon inflammatory affections. It came on after the
age of forty or fifty years. Such persons heard badly in a noisy
room. They beard the watch badly, but in a quiet room they
could hear quite well. This was characteristic of the affection.
In inflammatory troubles with the ear, the person often could
hear pretty well in a noise, while in a quiet room he heard badly.
These three symptoms went together : diminished bone-conduc-
tion, difficulty of hearing in a noise, and disproportion between
ability to hear the voice and ability to hear the watch. The
conditions on which presbykusis depended had not been deter-
mined, for as yet there had been no opportunities for post-
mortem examinations.
Dr. Sexton exhibited a glass ear-syringe and an ear forceps
with several attachments.
Dr. E. Dyer, of Newport, R. I., reported on a case of fistula
of the helix, in a girl of fourteen, which he had greatly benefited
by the application of the galvanic cautery.
The following papers were read by title : " A Case of Chronic
Otitis Media Suppurativa, resulting in Cerebellar Abscess, with
the Autopsy," by Dr. O. D. Pomeroy, of New York ; " Otitis
Media Suppurativa, Mastoid Disease, Pyaemia, Mastoid Opera-
tion, Recovery," by Dr. G. Bacon, of New York.
Officers for the Ensuing Year were then elected as fol-
lows: President, Dr. J. S. Prout; Vice-president, Dr. S. Sox-
ton; Secretary and Treasurer, Dr. -I. J. B. Vormyne ; Publica-
tion Committee, Dr. Vermyno, Dr. Blake, and Dr. J. 0. Green;
Committee on Membership, Dr. Carmalt, Dr. Kip]), and Dr.
Theobald.
Dr. F. L. Capron, of Providence, R. I., was elected to mem-
bership.
108
PROCEEDINGS OF SOCIETIES.
[N. Y. Mkd. Jock.
NEW YORK OBSTETRICAL SOCIETY.
Meeting of February 3, 1885.
The President, Dr. William M. Polk, in the Chair.
Placenta Prseviaand Twin Pregnancy.— Dr. H. T. Hanks
had recently heen requested by Dr. Dull to see a patient with
placenta pnevia, who, after the seventh month, had lost so much
blood that it was decided to effect an early delivery. After giv-
ing ether, Dr. Bull introduced his hand into the uterus, seized
the foot of the child, and extracted it, not waiting, on account
of the amount of blood which had been lost, for uterine con-
tractions. The placenta did not come away at once, and it was
found that there was a second child, which al*o was extracted
by the feet. The placenta was double. Very little blood
was lost after the extraction of the first child. Both children
were living, but one, being quite weakly, died within a few
days.
Dr. R. A. Murray inquired whether there had been repeated
haemorrhages, or only a single severe one.
Dr. Hanks replied that there had been slight attacks of
haemorrhage for a few weeks before delivery.
Dr. Murray had made the inquiry because, in his experience,
cases of placenta pnevia, so far as haemorrhage was concerned,
fell into two classes; those in which there was a slight drib-
bling of blood for some time before term, and those in which
there was but a single attack of haemorrhage, which was severe
and occurred at the onset of labor. In the latter class the
haemorrhage would almost certainly prove fatal to the child.
He referred to two instances which could be attested by certain
members of the society. In one the woman was in perfect
health, and had been out driving the day before an extremely
severe haemorrhage took place, which rendered her pulseless a£
the wrist and in the femorals, and caused the death of the
child.
Sarcoma of the Abdominal Wall and Peritonaeum.— Dr.
J. B. Hunter related the case of a woman of stout build, forty-
five years of age, who, about a year ago, noticed what she called
a small lump, just above the umbilicus, which was increasing in
size. A month ago the tumor appeared to be about four inches
in length and two and a half in breadth, irregular in outline, and
situated just above the umbilicus. At the latter point there was
an ulceration, which gave forth an offensive discharge. The
diag_w*is lay between sarcoma and fibroma. An incision hav-
ing been made across the tumor and the finger introduced, the
growth began to shell out like a fibroid from its capsule, but at
its lower border, while scarcely any effort was being made, the
finger entered the peritoneal cavity, and it was found that the
growth was attached to the omentum. It was removed with
very little difficulty. The peritonaeum was then found to have
on its surface little masses of epithelioma which bled easily-
Further exploration revealed a second tumor, similar to the one
removed, extending from the umbilicus nearly down to the
pubes, and apparently covering the greater part of the interior
of the abdomen with its flattened surface. It had had no con-
nection with the first tumor. The peritoneal opening made dur-
ing the removal of the upper growth was two inches and a half
in length, and was closed with difficulty on account of the de-
generated condition of the membrane. A drainage-tube was
inserted into the wound and an iodoform dressing applied.
Unexpectedly the patient survived, and had no bad symptoms
whatever. The drainage-tube was still in situ, and from it some
offensive pus had been withdrawn by aspiration. The patient
would be able to return to her home, although the malignant
disease would remain uncured. Dr. Hunter was disposed to
think the growth originated in the abdominal wall.
Ovulation in One Ovary at a Time.— Dr. H. C. Cue re-
ferred to an idea which had been termed rather fanciful, viz.,(
that ovulation took place in but one ovary at a time. He had
recently observed a few cases which seemed to confirm that
view. In three or four instances the patients suffered no pain
at one menstrual period, while at the next there was alwayf
severe dysmenorrhea, and in all but one of the patients the
ovary on the side to which the pain was referred, the left, w&f
enlarged and prolapsed.
Dr. Hanks asked Dr. Coe if he had observed whether the
corpora lutea in the two ovaries were apparently of the same or
of different dates.
Dr. Coe replied in the negative.
Dr. Hunter said that in one case of intense dysmenorrhea,
referred to the right ovary, which was enlarged, he removed
the ovary and the symptoms disappeared for a year. The left
ovary was closely adherent, and was not removed. With the
return of the symptoms he attempted to remove the other
ovary, but gave up the operation on account of the extent of
the adhesions. This case seemed to support the theory men-
tioned by Dr. Coe.
Dr. Hanks had two patients under observation whose
sufferings were much more severe at alternate menstrual
periods.
Vaginal Hysterectomy.— Dr. P. F. Munde presented a
uterus and related the following history: About two months
ago the woman was sent from the out-door department of Mt.
Sinai Hospital to his clinic, and her case was found to be a
typical one of epithelioma confined to the lips of a lacerated
cervix. Apparently the disease did not extend a line beyond
the lips, and, as the case seemed to be a very favorable one for
hysterectomy, he advised the patient to have the operation
done without delay. But she did not return for two months,
and at that time desired to have the operation performed. The
lips of the cervix were then much more infiltrated, but the dis-
ease had not extended into the parametrium. The uterus was
still perfectly movable. The greatest obstacle in the operation
was the narrowness of the vagina; it was difficult to expose
the cervix in the vaginal vault. The operation was performed
on the afternoon of the fourth day before the meeting. As in
two former cases he had experienced some difficulty in reaching
the broad ligaments and introducing ligatures with the patient
upon the side, in the present instance be undertook Martin's
method, with the patient upon the back. In this position, how-
ever, he found it almost impossible to reach Douglas's pouch,
and, on account of the presence of the specula, it was with the
greatest difficulty that he was enabled to lift the peritonaeum
with the finger. In the other cases, with the- patient on the
side, and using Sims's speculum, this step in the operation was
attended by no difficulty whatever. Having finally brought the
fundus of the uterus outside the vulva, he was able to pass the
ligatures and separate the side attachments with ease. The
elastic ligature having broken, he was obliged to use silk upon
the left side. Each vessel was ligated separately and little
blood was lost — perhaps as much as twelve ounces in all.
There was a slight amount of oozing from the posterior inci-
sion, between the peritonaeum and the vaginal wall, which
might have been avoided had he been able to pass sutures as he
had tried to do. The operation consumed about an hour and a
half. It would have been shortened had the first part been per-
formed with the patient upon the side, turning her upon the
back to evert the uterus and ligate the ligaments. The patient
remained pulseless at the wrist, and died thirty hours after the
operation.
The lessons which the case taught were, first, those concern-
ing the technicalities of the operation, and, second, those relat-
July 25, 1865. j
PROCEEDINGS
OF SOCIETIES.
109
ing to its justifiability. As bearing on the indications of the
Operation, lie referred to a paper which he read at the last
meeting of the American Gym-ecological Society. The oftener
we performed an operation the more dexterous would we be-
come, and the more successful would be the results. In the
paper referred to he had maintained that hysterectomy ought
to be performed in suitable cases of cancer of the uterus, and
he was of the same opinion still, although he might hesitate
longer before undertaking it.
Dr. Hanks said he had never removed the uterus, but he
bad often used the galvanic or Paquelin's cautery in cancerous
cases, and he would ask Dr. Munde whether he would not
have been justified in first giving the patient the benefit of a
trial of that method of treatment. Was it not just one of those
cases in which this form of treatment would have been indi-
cated ? If the cautery did not cure the disease, it certainly
arrested its progress, and afterward, if necessary, removal of
the entire uterus might be resorted to. He had witnessed the
hysterectomy in several cases, and he believed that in the ma-
jority of instances in this city the result had been unsatisfactory.
If, then, we could prolong life six months or a year, or even a
longer time, by the old method of partial removal of the uterus,
should it not be preferred to entire removal of the organ? He
doubted if we were justified in removing the uterus in cases in
which the cervix alone was involved; the risk was too great.
Dr. MrsiiE asked Dr. HaDks in what manner he would
operate.
Dr. Hanks replied that he would destroy the diseased tissue
by means of the galvanic tip.
Dr. Munde said he might have done too much, but he
thought Dr. Hanks would have done too little. If the patient
had declined to have hysterectomy performed, he would then
have drawn the cervix down to the vulva, made a circular in-
cision through the. vaginal vault all round, and amputated the
cervix with the galvanic cautery as high as possible without
touching the peritonaeum or bladder. He thought this method
better than Schroder's, in which the cervix was amputated with
the knife and the raw surfaces were united with sutures.
Dr. Hanks had no particular choice as to the manner in
which the cervical tissue was removed by the cautery, but the
point was that partial removal of the uterus was preferable to
hysterectomy. He knew of at least six women who had lived
a year, eighteen months, or two years after the use of the cau-
tery.
Dr. Munde said, in reply to a question, that in thirty-nine
per cent, of the cases of removal of the uterus the women had
remained well two years after the operation. Seventy -two per
cent, recovered from the operation. Those were better figures
than could be shown for any palliative treatment.
Dr. Hunter had a patient who had lived nine or ten years
after the removal of undoubted epithelioma of the cervix. He
thought hysterectomy would ultimately be limited to sarcoma
of the fundus.
Dr. Coe had seen Braun undertake to remove the uterus
with the patient upon the back, and fail because of the want of
room within the vagina.
A Large Hsematoma. — Dr. Munde said that two weeks ago
a woman came to Mt. Sinai Hospital with the history that six
weeks before she had had a miscarriage, and afterward had had
fever and a great deal of abdominal pain, and she gave an in-
distinct history of diffuse cellulitis. By gaslight her complex-
ion was waxy yellow or cachectic. A tumor was found occupy-
ing the whole of the posterior portion of the pelvic cavity, the
cervix being pushed against the pubic symphysis. It apparently
contained fluid, and was supposed to be a pelvic abscess of very
large size. The next morning the patient was seen by daylight,
and her complexion was less yellow, and this fact, with that of
the withdrawal of only blood by aspiration, led to the diagnosis
of haematoma. The patient's condition was not favorable, but
it was believed that absorption of so large a quantity of blood
would not take place, and he therefore proceeded at once to
make an incision, two inches in length, at the point of greatest
tension in the posterior vaginal wall. Eighteen ounces of co-
agulated blood escaped. A tumor was then recognized within
the cavity, of the size, form, and consistence of the human
heart. The patient's condition did not seem to justify him in
manipulating the tumor to discover its exact nature, but it was
thought it might be a sarcoma. The cavity was washed out
with a solution of corrosive sublimate, 1 to 5,000, a drainage-
tube was introduced, and also iodoform gauze. Within a day
or two frequent irrigations with the disinfectant were begun,
but the temperature rose to 103° to 104° F., falling after each
irrigation. As it was evident that the rise of temperature was
of septic origin, the cavity of the hasmatoma was explored, and
the tumor referred to, composed of coagulated blood, was found
to be breaking down. It was scraped out, and weighed eight
ounces; the cavity from which it came measured five inches in
diameter. The irrigations had been kept up, the temperature
had fallen, and the patient was doing well. He did not think
absorption of the fluid would have taken place had it been
allowed to remain ; the largest lmematocele which he had known
to he absorbed was not larger than his two fists. In this case
it was extra-peritoneal.
Perforation of the Cervix Uteri by a Laminaria Tent.—
Dr. C. C. Lee related a case which suggested the advisability of
caution in using laminaria tents for dilating the cervix uteri.
The patient, a middle-aged single woman, entered his service at
the Woman's Hospital with what was believed to be a submu-
cous fibroid attached to the anterior wall of the uterus a short
distance above the internal os. The vagina was narrow and the
cervix long, making it difficult to outline the growth with the
finger, and, as frequent haemorrhages pointed to the necessity
of adopting some efficient mode of treatment, it was decided to
dilate the cervical canal. Laminaria tents were introduced,
carefully watched, and changed sufficiently often. They were
held in positiou by carefully adjusted vaginal tampons, which
were never very tightly packed. The uterus was slightly ante-
verted. On the removal of the tents on the last occasion — they
had not been put in by himself, but by a careful and experienced
bouse surgeon — he was astonished to find a large perforation on
the anterior surface of the cervix at the internal os. It was
evident that these tents, of which two were then in the canal,
had, by their expansion and by the pressure of the tampon, per-
forated the anterior side of the cervix at the vaginal junction.
This was the first time he had known the accident to occur, but,
on inquiry among his friends, he had learned of two other simi-
lar cases, the tents used being of laminaria. In his case, instead
of making the usual incision, he divided the cervix posteriorly
up to the internal os, and anteriorly up to the perforation, and
was then able to reach the greater portion of the tumor. Car-
bolized cotton was applied to the cervix, and the patient, not-
withstanding her reduced condition, recovered. The result of
the granulating surfaces was such as to call for trachelorrhaphy,
after which the cervix was left in a pretty fair condition.
Dr. Munde bad met with cases in which an ulcer in the wall
of a long cervix had been formed by stem pessaries and tents
which the physician had failed to introduce through the inter-
nal os. In some cases a little force was required to push the
instrument through the internal os, and he had no doubt that
inexperienced or careless persons might make a mistake and
cause an injury of the cervical wall. A laminaria tent would
be more likely to cause ulceration than one of tupelo.
110
MISCELLANY.
IN. Y. Mku. Jour.,
Dr. Lee remarked that it was possible the tent used in this
case was a tupelo instead of laminaria, but he thought it was the
latter. The accident could not have arisen from the cause spo-
ken of by Dr. Munde, because the internal os was well dilated
when the last tent was removed. He could readily understand,
however, that, if a tent was not made to pass the internal os, it
might press against the solid tissue of the wall and cause ulcera-
tion.
Exfoliation of the Mucous Membrane of the Rectum.—
Dr. Munde had recently performed Emmet's operation upon the
prolapsed vagina in two cases, the immediate result in both be-
ing perfectly satisfactory. In one there was a temperature of
from 101° to 102° F., which was not regarded as having any
special significance. On the tenth day, when he was about to
remove some of the stitches, the house surgeon called his atten-
tion to a slough protruding from the rectum. He then exam-
ined the patient, and removed fully six inches of the mucous
membrane of the rectum, which was gangrenous and very offen-
sive. He supposed there would finally be stricture of the rec-
tum. Was it possible that narrowing of the posterior vaginal
wall could have interfered with the rectal circulation and pro-
duced the result? In reply to a question, he said rectal etheri-
zation had not been employed.
Dr. Hanks referred to a case in which there was discharge
of a part of the mucous membrane of the rectum every few
weeks, and asked what the treatment should be. This patient
had retroversion, and formerly casts of the lining membrane of
the uterus were discharged.
Dr. Munde further remarked that he believed this condition
was called exfoliative colitis. About ten years ago Dr. Peaslee"
presented long casts of the mucous membrane of the bowel. Dr.
Munde had seen two instances, in one of which there was retro-
version of the uterus, and in the other chronic oophoritis. He
did not have an opportunity to institute treatment for the rectal
trouble.
Dr. C. Mackenzie inquired whether any of the patients had
suffered from diarrhoea. He had seen a case in which there was
morning diarrhoea, with marked retroversion of the uterus, and
more recently a fissure of the anus had been discovered.
Henry J. Garrigues, M. D.,
B. F. Dawson, M. D.,
Frank P. Foster, M. D., ex officio,
Committee on Publication.
§1 r s z 1 1 1 a rt p .
The Failure of the American Medical Association to organize the
Ninth International Medical Congress. — The following appeared in
the editorial columns of the " Maryland Medical Journal " for July
18th : "Those members of the medical profession who have an earnest
and abiding interest in the growth of scientific medicine and in the de-
velopment of the highest aims of the profession in this country can not
but feel the need of a national organization thoroughly capable of meet-
ing the highest purposes of a scientific body. The American Medical
Association has undertaken for some years past to represent the real
wants of the American profession. It is, however, a delegated body,
and in the very nature of its structure contains such inherent weakness
that it has not been able to grapple with the serious questions which
have been propounded to it. The membership of the association is as
fluctuating as its actions, and it has so controlled the interests of the
profession as to forfeit the right of respect to which the organization
is entitled from the leading minds in the profession. The association
has never been able to do the highest order of scientific work, and from
year to year has so constructed its offices and committees in the inter-
ests of its floating membership that it was not capable of drawing into
its ranks the full force and strength of the profession in this country.
The association has shown itself totally incapable of dealing with serious
and important scientific interests, as has been most conspicuously demon-
strated by its recent action at New Orleans in referenc*e to the Ninth
International Medical Congress, which it proposed to hold under its
auspices. It was shown at New Orleans that a few determined and
bold men were capable of capturing its membership and of upturning
all of the work delegated to an important committee at its previous
meeting in Washington. The result of this action of the association
has cast a shame and a blot upon the good name of the entire profes-
sion in this country, and it has forfeited all the reputation the associa-
tion may have had as a fair, liberal, and high-toned scientific body.
Under the leadership of a few malcontents the association has degen-
erated to the level of a ridiculous and pharisaical institution, utterly
unworthy of confidence and respect. So far as the fortunes of the In-
ternational Medical Congress are concerned, it is now evident that the
association is wholly incapable of conducting the Congress under its
auspices. The withdrawal of the leading members of the profession
from all connection with the present organization tells its own story,
and very plainly says the Congress must be re-organized on some other
basis than the one proposed by the American Medical Association, if it
is to be a success. In other words, the association has so seriously
blundered in this affair that it must resign its authority as a leading
spirit in the re-organization of the Congress. Indeed, it seems to us
that the only course now left open to the association is to abstain from
further participation in the arrangements for the Congress, and that it
leave this matter in the han':s of the medical profession at large, which
can be depended upon to re-organize the Congress on a successful basis.
We have no doubt that the profession at large can move intelligently
in this matter. If representative men from all sections of the country
can be brought together to confer upon the present outlook of the Con-
gress, arrangements can be made which will bring order out of chaos,
and set the affairs of the Congress on a sure and influential footing."
The Missouri State Board of Health announces the appointment of
committees to make special investigations as follow-:
Prevailing diseases among live stock in Missouri ; also condition and
care of stock-yards, cars, etc., at points of concentration or distribution
— Committee: Mr. Gentry and Mr. Prather. The influential factors in
the causation of endemic or local epidemic diseases — Committee: Dr-
Griffith and Dr. Homan. The sources, quality, means of distribution,
etc., of public water supplies in Missouri — Committee : Dr. Merrell and
Dr. Cox. The sanitary care of railway and river transportation lines,
including depots, landings, stations, wharf-boats, round-houses, and pas-
senger and sleeping coaches — Committee: Dr. Homan and Mr. Gentry,
Domestic and general sanitation in towns, villages, and country-homes —
Committee : Dr. Goben and Dr. Griffith. The condition of asvlums,
poorhouses, jails, workhouses, and other charitable or penal institutions
with reference to the health of the inmates — Committee: Mr. Prather
and Dr. Merrell. The hygienic care of the school population and of
public-school buildings and premises — Committee : Dr. Cox and Dr-
Goben.
The Western Society for Psychical Research has been organized in
Chicago, the purpose of which is to be commended, since it proposes
to investigate certain matters most of which are usually left to enthu-
siasts and charlatans. From an excellent address by the president, Dr.
A. Reeves Jackson, we learn that the work of the society has been
divided among five sections : 1. Thought-transference. 2. Hypnotism,
clairvoyance, and somnambulism. 3. Apparitions and haunted houses.
4. Physical phenomena. 5. Psychopathy (including what is popularly
known as mind-cure, faith-cure, metaphysical treatment, magnetic heal-
ing, etc.).
The Nomenclature of Auscultation and Percussion Signs. — The
"Glasgow Medical Journal" publishes the following tabular list of
terms proposed by the British members and the American member of
the committee appointed at the meeting of the International Congress
July 25, 1885.1
MISCELLANY.
Ill
in 1881 to report on a uniform nomenclature of physical signs which
occur in connection with the respiratory system :
PALPATION.
AMERICAN LIST.
Dr. Austin Flint.
Vocal fremitus.
BRITISH LIST.
Dr. Powell and Dr. Mahomed.
1. Vocal fremitus.
2. Rhonchal fremitus.
S. Fremitus.
Rhonchal fremitus.
Friction fremitus.
1. Tympanitic .resonance.
2. Amphoric resonance.
3. Diminished resonance.
ness.
4. Absence of resonance.
ness.
5. Increased resonance.
PERCUSSION.
Tympanitic resonance.
Amphoric resonance.
Diminished resonance.
Dull-
Flat-
Dullness.
Absence of resonance. Flatness.
Increased or vesiculotympanitic
resonance.
Not included.
6. Bell sound. [" This term," says
the reporter, " is applied, by
some English writers, to a
sound produced by percussion,
a coin being used as a plex-
imeter, and the ear applied to
the chest. It is supposed to
be characteristic of pneumo-
thorax."]
AUSCULTATION.
First Group. Varieties of Breath Sounds.
1. Exaggerated. Syn. Puerile. Exaggerated, etc.
Compensatory. Supplement-
ary.
2. Diminished. Syn. Feeble. Diminished, etc.
Weakened vesicular murmur.
3. Suppressed. Syn. Absence of Suppressed, etc.
breath sound.
4. Prolonged expiration. General Prolonged expiration. High or low
or local. in pitch.
5. Interrupted respiration. Syn. Interrupted inspiration, etc.
Jerking, wavy, cog-wheeled.
6. Tubular. Syn. Bronchial. High- , Tubular. Bronchial.
pitched blowing.
7. Vesiculo-tuhular. Syn. Bron- Broncho-vesicular. Syn. Vesiculo-
cho-vesicular. Harsh, coarse, tubular,
sub-tubular.
8. Amphoric. Amphoric.
9. Cavernous. Cavernous.
Second Group,
1. Rhonchi. Dry musical sounds,
(a) Sonorous, (b) Sibilant.
2. Stridor.
3. Rales. Syn. Bubbling rales,
etc. (a) Medium, (b) Large.
High or low in pitch.
4. Gurgling.
5. Clicking.
6. Crepitation. Syn. Crepitant
rale.
7. Metallic tinkling. Metallic tinkling
8. Splash. Splash.
9. Friction, (a) Dry, (b) Moist. Friction.
Third Group. Varieties of Voice Sounds.
Adventitious Sounds.
Rhonchi, or dry bronchial rales.
(a) Sonorous, (ft) Sibilant.
Stridor.
Moist or bubbling rales, (a) Me-
dium, (b) Large, (c) Small.
High or low in pitch.
Gurgling.
Clicking.
Crepitant rale, or crepitation.
1. Increase of vocal resonance.
2. Diminution or absence of vocal
resonance.
3. Bronchophony.
4. Pectoriloquy.
5. jfCgophony.
Increase of vocal resonance.
Diminution or absence of vocal
resonance.
Bronchophony.
Pectoriloquy.
vEgophony.
The Sanitary Convention at Ypsilanti, Michigan, held June 30th
and July 1st, was attended by about twenty physicians and health
officers from other places, besides the physicians of Ypsilanti, the offi-
cers of the State board of health, and a number of prominent citizens.
Among the physicians who took part in the proceedings were Dr. Avery,
of Greenville; Dr. Vaughan, of Ann Arbor; Dr. Whelan, of Hillsdale,
Dr. Kellogg, of Battle Creek; Dr. Palmer, of Ann Arbor; Dr. Kinne,
Dr. Wight, and Dr. Lyster, of Detroit ; and Dr. French, of Ypsilanti.
Much interest was manifested in the proceedings by the citizens of
Ypsilanti. These periodical semi-popular conferences seem to be a
happy device of the State board of health.
The Editor of the " British Medical Journal," Mr. Ernest Hart, is
reported to be a candidate for a seat in Parliament, and to have prom-
ised that, in case he is elected, he will vote for the unconditional repeal
of the Contagious Diseases Acts (referring to venereal diseases). The
" Medical Times and Gazette " remarks that " there is a great excuse
for medical men, worried by the everlasting opposition to their benevo-
lent intentions, throwing up the sponge and saying, as Mr. Hart prac-
tically does, ' Well, have your own way, but don't blame me if it turns
out badly.' "
Boston and the International Medical CongTess. — The " Medical
News " learns that the following-named gentlemen have asked to have
their names added to the list of signers of the resolutions adopted in
Boston declining to hold office in the proposed Congress as now organ-
ized : 0. W. Holmes, William H. Baker, David W. Cheever, James C.
White, and William F. Whitney, of Boston; G. P. Conn, of Concord,
N. H. ; F. H. Gerrish and S. C. Gordon, of Portland, Me. ; E. P. Hurd,
of Newburyport, Mass. ; and Nathan Allen, of Lowell, Mass.
The New York Polyclinic. — We congratulate the faculty of the
Polyclinic upon the continued prosperity of the institution. It appears
by the annual announcement for the session of 1885 to 1886 that the
session which opened September 22, 1884, was attended by two hundred
and twenty-nine practitioners. From the beginning the Polyclinic has
been under excellent management, and there can be no doubt of its
enduring success.
The International Medical Congress. — Dr. W. A. Hardaway, of St.
Louis, asks us to state that he has sent in his resignation as president
of the Section in Dermatology and Syphilis of the Ninth International
Medical Congress. We learn that Dr. Thomas T. Sabine, of New York,
and Dr. Thad. A. Reamy, of Cincinnati, have declined to serve in the
positions to which they were appointed by the new committee. The
" Medical News " announces that Dr. George J. Engelmann, of St. Louis,
has resigned from the committee.
The Capias served on Dr. Shoemaker in Chicago has, as we learn
from the " Philadelphia Press," been quashed. It was in an action
brought against him by a Mr. Merritt, of Troy, N. Y.
THERAPEUTICAL NOTES.
An Untoward Effect of Arsenic on the Skin in Children. — Guaita
("Arch, di Patol. Infantil." ; " Dtsch. Med.-Ztg."), who seems to use
Fowler's solution freely in the treatment of children's diseases, continu-
ing its administration for four or five months, and increasing the daily
amount given from two drops to eighteen or twenty, reports that, in
fourteen out of eighty cases, he has observed a peculiar blackish dis-
coloration of the skin as a consequence. It appears either toward the
close of the aisenical course or, more rarely, about a month after its
completion. It shows itself at first on the neck, and then on the
breast, the abdomen, and the hands, while it either spares the face, the
lower limbs, and the back altogether or is less pronounced on those
parts. It is never accompanied by other disturbances, and it disap-
pears in at least a month, with marked desquamation. It appeals from
citations in the same journal that a dusky discoloration of the skin was
long ago noticed as one of the effects of the prolonged use of arsenic,
even in the form of baths of arsenical mineral waters.
Old and New Methods of treating Congenital Syphilis. — Pro-
fessor Monti, of Vienna, contributes to the "Archiv fiir Kindcrheil-
112
MISCELLANY.
[N. Y. Mki.. JotoK.
kunde " an article which the " Deutsche Medizinal-Zeitung " thus sum-
marizes : In the inunction treatment, use has been made of mercurial
ointment, oleate of mercury, Beyersdorf and Unna's mercurial-plaster
preparation, and mercurial soap. All these substances are very prompt
in their action, and, used in proper quantities, never give rise to saliva-
tion or signs of irritation of the mucous membrane of the mouth, but
they are not suitable for sucklings, for, besides their irritating the skin
and producing erythema, eczema, and boils, the too rapid and extensive
absorption of the mercury may lead to a quickly developed ansemia,
often resulting in cerebral or pulmonary oedema and putting a stop to
the child's increase in weight, in spite of judicious feeding. Since the
inunction treatment, moreover, neither shortens the duration of the
disease nor diminishes the frequency of relapses and sequelae, the use
of calomel associated with iron is much more to be recommended, for
instance after this formula :
Calomel 1 .} grain ;
Lactate of iron 3 grains ;
White sugar 45 "
Divide into ten powders.
From one to four are to be given daily, according to the weight of
the child.
Calomel may be given continuously, without deranging the digestive
apparatus, until all the syphilitic manifestations have disappeared. If,
however, in spite of the minuteness of the dose, anaemia shows itself,
the treatment must be interrupted at once, and lactate of iron given,
or, in case of cerebral anaemia, the ethereal tincture of chloride of iron.
After every course of treatment with calomel, Monti uses the follow-
ing :
Saccharated iodide of iron.. . . 15 grains;
White sugar 30 "
Divide into ten powders, from one to three of which are to be given
daily, according to the child's age, their use being kept up until there
is no longer any enlargement of the spleen and the skin has regained
its healthy tint. Monti has observed that, under this method of treat-
ment, relapses are less common and less severe, sequelae, especially
rickets, are lighter, and the children gain in weight.
If intestinal disturbances contra-indicate the internal administration
of calomel, or if threatening symptoms seem to call for more energetic
treatment, the drug may be used subcutaneously, after this formula :
Calomel 8 to 15 grains ;
Gum mixture, ) „„, „ . .
' V each 75 minims.
Glycerin, )
From half a syringeful to a syringeful to be injected every second
or third day, preferably over the chest-wall. Abscesses will often form,
in spite of the utmost care in the use of the injections.
Van Swieten's solution (a one-to-one-thousand solution of corrosive
sublimate) was used by that author in doses of ten drops, in milk, three
times a day, the dose being gradually increased until a hundred drops
were taken daily ; orjie prescribed :
Corrosive sublimate -f grain ;
Distilled water 10 drachms;
Syrup U
From two to four teaspoonfuls to be taken daily, after eating.
In the form of baths, corrosive sublimate is very slow in its action,
and is employed only when the internal administration of mercury is
inadmissible. The following formula is given :
Corrosive sublimate 15 grains;
Chloride of ammonium 2 J drachms;
Distilled water 6 ounces.
To be added to two baths.
Corrosive sublimate is most adapted to injections. [The formula
which follows this statement seems to contain a dangerous error; we
therefore do not reproduce it.] The injections are generally well borne,
although not so welt as by adults, and they do their work more speedily
than other methods of treatment. Abscesses and indurations of the
subcutaneous cellular tissue occur. The duration of the disease and the
occurrence of relapses and sequelae are not affected by the injections ;
within the first two years of life the treatment should be repeated from
four to eight times (being continued from five to twenty days each
time), in order to effect a radical cure.
Albuminate of mercury is equally efficient in the form of injections,
but the solution does not keep well ; it is apt to become turbid, and
then it causes abscesses, etc. Peptonate of mercury keeps better, but
it has no advantages, and the same is true of formamide of meri ury.
injections of which are very painful.
Protiodide of mercury is very serviceable, especially in affections of
the bones :
Protiodide of mercury l£ grain;
Lactate of iron 3 • grains ;
White sugar 45 »
Divide into ten powders; from one to three to be taken daily.
Severe colic and intestinal catarrh are commonly produced by this
drug, even when opium is used with it.
Henoch often employs black oxide of mercury, in the form of pow-
ders, carrying the dose up to a seventh of a grain, twice a day ; but
Monti has found that it frequently causes vomiting.
Tannate of mercury, from one seventh to half a grain, from two to
four times a day, is very well borne and is quite as rapid and favorable
in its action as calomel.
As regards the iodine treatment, Monti gives from three to six pap-
spoonfuls [? daily] of a one-per-cent. solution of iodide of potassium,
and adds from three to eight drachms of the iodide to the bath. The
tardy action of the drug and its interference with the nutrition when
its use is long continued have led the author to prefer the saccharated
iodide of iron, which is especially well borne by children, never causes
iodism, and corrects anaemia ; but it is suitable only in cases where
energetic treatment is not indicated. For children between three and
twelve months old, it is sufficient to give from a third to half a grain,
in milk, three or four times a day; children from a year to two years
of age may take from four grains and a half to six grains daily.
Silk-worm Gut as a Material for Ligatures. — Guermonprez and
Bigo lately submitted a communication to the Paris Soeiete de therapeu-
tique (" Gaz. hebdom. de med. et de chir.") on the use of crin de Flo-
rence in surgery. They conclude that, if its ends are cut off and it is
macerated for at least a month in a watery antiseptic solution (it must
not be boiled), it is the best thread for sutures. It is tenacious, pliable,
and better borne by the tissues than either hemp, linen, or silk. For
ligatures applied to small vessels it is not so good as catgut, but for
large vessels and the pedicles of tumors it is to be preferred.
The Paradoxical Action of Quinine. — Merkel ("Dtsch. Arch. f. klin.
Med." ; " Ctrlbl. f. klin. Med.") relates the case of a woman who had
fever which was taken to be malarial. She was given three grains of
hydrochlorate of quinine, and in an hour she showed faintness, weak-
ness, and stupor. She then had a chill, and her rectal temperature rose
to 104-6° F. The temperature fell gradually without the occurrence of
sweating. The same effects were produced whenever a small dose of
quinine was given.
A Dressing for Phagedenic Chancre. — The " Union medicale " at-
tributes the following formula to Terrillon :
Pyrogallic acid 1 part ;
Powdered starch 4 parts.
Mix carefully. In cases of ragged phagedenic chancres, with multi-
ple prolongations, the powder is to be blown into the deep parts with a
bellows. The application should be repeated twice a day. The prepa-
ration should be freshly made and preserved against moisture in a well-
corked bottle.
A Diuretic Mixture. — The same journal credits Billroth with the
following formula :
Acetate of potassium, / , -
r ' > each 5 parts ;
Nitrate of potassium, )
Distilled water 200 "
Syrup of raspberry 20 "
A teaspoonful to be given night and morning in cases of acute artic-
ular rheumatism. The affected joints are to be painted with tincture of
iodine, covered with cotton, and kept absolutely motionless. If peri-
carditis occurs, a blister is to be applied over the precordial region.
THE NEW YORK MEDICAL JOURNAL, August 1, 1885.
LECTURES ON
ELECTRICITY IN MEDICINE,
DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI-
VERSITY OF VERMONT, BURLINGTON,
By AMBROSE L. RANNEY, M. D., New Yoek.
{Continued from page 87.)
Galvanization of the Cervical Sympathetic. — This
method has afforded relief, according to published cases, in
vaso-motor and trophic disturbances of the nerve-centers,
the eye, viscera, muscles, joints, and skin. Thus, for ex-
ample, cases of cure of epilepsy, atrophy of the optic nerve,
Basedow's disease, progressive muscular atrophy, lead-palsy,
scleroderma, chronic rheumatic arthritis, bulbar paralysis,
neuralgias of various types, and many other conditions have
been reported by means of this method. Respecting this
step, Erb wisely remarks as follows: "There can probably
be no doubt of the correctness of a part of these observa-
tions, but this does not by any means imply that the cervi-
cal sympathetic is responsible for such results."
When we review the structures which compose the neck
and recall the numerous connections which exist between
the sympathetic cords, the pneumogastric nerve, the brain
and cervical segments of the cord, the medulla oblongata,
the brachial and cervical plexuses of nerves, etc., it be-
comes clear why De Watteville applies the term " sub-aural
galvanization" and Erb the term "galvanization of the
neck" to this special procedure.
The steps required to influence these parts by Meyer's
method consist in the application of a small electrode (ca-
thode) under the angle of the jaw and adjacent to the hyoid
bone, and then crowding it backward and upward against
the vertebral column, the positive electrode (of larger size)
being placed over the seventh cervical spine. The current
may be stabile, labile, or interrupted ; or the polarity may
be changed from time to time during the sitting of from
one to three minutes. Six to ten galvanic cells of the
Grenet variety are sufficient. The application may be uni-
lateral or bilateral, according to the demands of the case.
Corning has devised an instrument which insures carotid
compression with galvanization of the neck for the treat-
ment of cerebral hyperemia and some other morbid condi-
tions.
Benedict places the positive pole in the jugular fossa,
and the negative pole upon the superior cervical ganglion.
General Faradization. — This method of administer-
ing electricity was first employed by Beard and Rockwell.
By this procedure the entire body is subjected to secondary
faradaic currents of varying intensity. It is applicable
chiefly to those forms of nervous disturbance which are
associated with general debility, poverty of the blood, spe-
cial diatheses and cachexias, hysterical affections, skin dis-
eases, persistent chronic inflammations, and other results of
low vitality or functional derangements of the organs.
To apply this method, the patient must be undressed or
very loosely clothed. The feet are immersed in a bowl of
tepid water with a little salt added, in which the cathode
is also placed after being connected by means of a rheo-
phore to the binding-post of the secondary coil of a faradaic
machine. The anode is held in one hand of the physician,
and his other hand (well moistened in salt water) is applied
to all parts of the surface of the patient's body. If the
subject can bear it, a large electrode covered with absorbent
cotton and flannel, or with a soft sponge, is employed in place
of the hand. The application should begin at the head and
terminate at the feet — the strength of the current being
modified from time to time as the feelings of the patient
may demand. The extremities and back should have vig-
orous stimulation, the nerves of the neck should be influ-
enced by a much weaker current, and the coeliac plexus
should be influenced by a stabile application of a few min-
utes over the epigastrium. The entire duration of the
application occupies from ten to twenty-five minutes. It
may be applied as often as three times a week if necessary.
Personally, I can attest the efficacy of this treatment as
a general tonic. I have witnessed immediate effects from
it in a large number of my cases, and I employ it constantly
in a modified form.
In case the hand of the attendant is to be employed as
an electrode, I would advise you to use the instrument
which I now show you as a great improvement over the
way described by the inventors of this method. It is called
the electric bracelet. It is placed upon the right wrist of
the attendant over a pad of wet absorbent cotton, and the
rheophore is screwed into the binding-post upon it. The
right hand is then wet in salt water and used as previously
described. By this instrument the hand of the attendant
is alone subjected to the current, and the fingers can detect
muscular contraction in the patient even when too feeble to
be seen easily. As an adjunct to massage, I employ this
useful instrument with decided benefit.
General Galvanization. — The steps required by this
method are similar to those previously described, except
that the constant-current battery is employed in place of a
faradaic machine.
Central Galvanization. — The cathode is placed over
the epigastrium. This electrode should be of large size.
The anode is stroked over the forehead, with a current of
about two milliamperes, for two minutes; then made stabile
over the cranium for about two minutes; then moved up
and down the neck on each side for the same duration ;
finally it should be moved along the length of the spine for
about five minutes. This method was a favorite one with
the late Dr. Beard, who reported cures of gastralgia, hys-
teria, hypochondriasis, nervous dyspepsia, and many of the
symptoms of cerebral and spinal neurasthenia by its con-
tinued use. In two cases of gastralgia in which I per-
sonally employed it for some time I obtained an absolute
recovery.
The Electrical Bath. — This method of administration
of electricity to a patient may be accomplished by usino- a
metal tub, or one which is composed of a non-conductor. If
a metal tub is employed, the patient must be protected
114 PORTER: PHTHISIS AND PNEUMONIA,
THEIR RELATION TO SYPHILIS. [N. Y. Med. Jocr.,
from actual contact with it. This is usually accomplished
by means of wooden slats or some other medium of support
for the patient when immersed. If the bath-tub is of
metal, one rheophore of the battery employed is attached
to the tub, while the other is attached to an electrode held
by the patient or placed in contact with his body. If the
tub is of a non-conducting material, both electrodes may be
placed in the water. The electrodes employed should be
very large (often running the entire length of the tub), in
order to allow of as great a diffusion of the electricity as
possible. The fluid in the tub may be simple water, or,
preferable, a solution of salt, soda, or an acid.
Personally, I am not a strong advocate of this method
of treatment. It violates one of the fundamental principles
of electrical treatment of localized affections in that it does
not confine the polar action to the part or parts diseased.
In the second place, I have not found its tonic action to
equal that of general faradization or general galvanization.
Strong claims have been made in its favor as a remedy
for tremor (especially of the alcoholic and mercurial varie-
ties) and for chronic articular rheumatism, but I am not
yet convinced that they are to be regarded as well-estab-
lished.
If you desire to try this method of treatment in any
case, it is well to know that the temperature of the bath, as
well as the strength of the current employed, should be
modified by the condition of your patient. The duration
of the bath should never exceed thirty minutes, and ten
minutes will generally suffice. The current should be strong
enough to be perceived by the patient in all cases.
The Relief of Painful Points. — One of the most
generally useful effects of electricity is the relief which it
affords in many cases to pain. Of all the methods of treat-
ment of neuralgia now employed, I consider electricity, in
some of its various forms of application, by far the most
efficacious. Personally, I have almost discarded internal
medication for the relief of this class of sufferers. You
have personally witnessed in one or two cases brought be-
fore you the immediate relief which follows the application
of electricity to painful points, and you have seen neuralgia
cured at one sitting by the same agent. Do not understand
me, however, as maintaining that this can be accomplished
in all cases. Repeated applications are demanded, as a rule,
and, in some instances, months of treatment are required to
insure a cure of this distressing malady.
In the majority of subjects afflicted with neuralgia, pain-
ful points may be detected along the course of the affected
nerve or its branches. These are situated, as a rule, where
the nerve gives off a branch or bifurcates, and also where it
passes through a foramen. Sometimes it is necessary to
make pressure along the course of the nerve to detect the
existence and seat of these points.
Now, it should be remembered by each of you that the
successful treatment of neuralgia depends largely in some
cases upon the direct treatment of these painful points. They
seem in some way to have a relationship with both the pro-
duction and cure of neuralgia, as well as spasm of the mus-
cles, ataxic symptoms, and other forms of nervous diseases.
These points may be the seat of a localized periostitis, a
circumscribed inflammatory exudation, a neuritis, an en-
larged gland, and many other conditions which create nerv-
ous phenomena. In a few instances the symptoms even
of ataxia have been relieved, by the electrical treatment of
painful points in the region of the spinous and transverse
processes of the vertebrae, by men of note, among whom
may be mentioned Brenner, Remak, Meyer, Legros, and
others.
The steps which you should employ in the treatment of
painful points are as follows : 1. Use the galvanic current,
employing from three to eight Grenet cells. 2. Apply the
anode to the painful spot, and keep it stationary at that
point. 3. Place the cathode at some indifferent point, pre-
ferably the sternum. 4. Do not use a current which will be
excessively painful to the patient, nor exceed five minutes
in the application. I frequently do not allow the duration
of the current to exceed two minutes at a sitting. It is ad-
visable, in persistent cases, to make the applications daily.
Of late some experiments have been made, with appa-
rent benefit, by having patients of this class wear over the
painful points a piece of metal, connected with another piece
of metal (which is also in contact with the skin) by an insu-
lated wire. The best metals are zinc and copper. They
should be brightly polished before the application, and
should have a piece of dampened linen between them and
the skin. They may be worn continuously for weeks, or
changed each day on retiring and rising.
Some authors recommend the employment of very feeble
galvanic currents for an hour or two at each sitting, the
anode being placed over the painful point. Le Fort goes
so far as to suggest the propriety of applying such currents
continuously for weeks, byr means of ordinary rheophores
and electrodes, when fatty changes, contractures, or reflex
paralyses are to be combated.
[To be continued.)
Anginal Communications.
OBSERVATIONS ON
PHTHISIS AND PNEUMONIA
IN THEIR RELATION TO SYPHILIS.
A STUDY OF ONE HUNDRED CASES IN WHICH THESE AF-
FECTIONS WERE ASSOCIATED.
By WILLIAM H. PORTER, M. D.,
PROFESSOR OP CLINICAL MEDICINE AND PATHOLOGY IN THE NEW TORK POST-
GRADUATE MEDICAL SCHOOL AND HOSPITAL ; CURATOR OF THE PRESBY-
TERIAN HOSPITAL, ETC.
Most of the clinical data used in the preparation of this
paper have been taken from the records of one hundred un-
selected cases recorded at the author's medical clinic at the
New York Post-Graduate Medical School and Hospital ; the
pathological data from the post-mortem records of the
Presbyterian Hospital.
Syphilitic pneumonia in children has long been recog-
nized as a distinct and common lesion, but in adults it is
August 1, 1885.] PORTER: PHTHISIS AND PNEUMONIA, THEIR RELATION TO SYPHILIS.
115
either entirely ignored or given but a passing notice by
the writers on clinical medicine.*
Latent syphilis, both of the acquired and congenital
variety, as an ajtiological factor in disease, has occupied the
attention of the author for a number of years past, and he
has collected much pathological material bearing not alone
upon its influence upon the pulmonary tissue, but upon every
organ and tissue of the body. Pulmonary syphilis is best
defined as a condition of the lungs in which there is a pro-
gressive thickening of the walls of the vesicles ; this change
is often associated with inflammatory deposits, gummy for-
mations, which, degenerated into cheesy masses, become
encapsulated or liquefy, and give rise to cavities. The first
is best classified as syphilitic pneumonia, the second as
syphilitic phthisis.
The primary origin can only be settled by accepting the
terms syphilitic pneumonia and phthisis.
The first necropsy in connection with a typical clinical
history was made in 1878, and in this instance there was no
question of the existence of acquired syphilis, and the ex-
emption from inherited phthisis was equally positive. The
clinical history and the results of the autopsy evidenced a
syphilitic instead of a tubercular origin for the pulmonary
lesion, and since this time a number of similar instances
have been noted.
The lungs removed from a diabetic subject f are inter-
esting, as illustrating several important points :
1. Pulmonary consolidation and softening, with the for-
mation of cavities, may occur in diabetic patients independ-
ently of any tubercular phthisical process, which strongly
suggests a similar development under other circumstances.
2. Consolidation, softening, and the formation of cavi-
ties may occur without the formation of tubercles, as shown
by the fact that no tubercle tissue, in the instance quoted,
could be made out by the microscope, as well as by the fact
of the absence of the Bacillus tuberculosis, which corresponds
to Koch's theory.
3. Taken together with a number of other necropsies,
this one establishes, from a pathological standpoint, the ex-
istence of a syphilitic lesion with the formation of cavities
at the apex of the lung.
4. It substantiates the clinical observation that syphilitic
lesions of the lungs frequently commence and are most
marked at the apex, and diminish from apex to base.
5. Both lungs are involved, one usually more than the
other. The base and anterior portions of the lungs are
rarely involved at first. J
* " Dictionary of Medicine," Quain, American Edition, New York,
1883, p. 900.
f "New York Medical Journal," January 31, 1885, p. 139; Ibid.,
April 11, 1885.
X This form of pulmonary lesion has been quite extensively de-
scribed by :
Greenfield, W. S. — On Visceral Syphilis. London "Pathological
Transactions," pp. 249, 208. London, 1877.
Goodhard, J. F. — Phthisis of Fibroid Forms ; History of Syphilis.
Op. citat., p. 313.
Green, T. Henry— Syphilitic Disease of the Lung. Op. citat, p.
331.
Pye-Smith. — Tertiary Syphilis affecting Lung, p. 334.
Every day cases present themselves at the clinic which
might be diagnosticated as an ordinary disease and passed
by, but a careful investigation invariably reveals a hidden
syphilitic taint, which has evidently excited and has served
to keep the disease in motion. This assertion may appear
dogmatic, but careful investigation leads to but one result.
If the rules for diagnosis to be laid down are found suffi-
ciently strong to warrant an inflexible opinion, the main
question is settled. From the histories of the first thou-
sand cases treated at my clinic, one hundred, or ten per
cent., were taken as the basis of this paper. Of the remain-
ing nine hundred, many had pulmonary lesions and diseases
of the various organs, which, in my opinion, were of syphi-
litic origin, and which, as a rule, responded to a certain line
of treatment. This ten per cent, of all the cases is a large
proportion; but, if the pulmonary cases alone be taken,
fifty per cent, or more would be traceable to the same cause.
These facts are sufficient to attract attention, and to indicate
how frequently syphilis may figure as a cause of disease.
Of the one hundred patients, fifty-two were males and
forty -eight females ; but, while these figures are true of this
particular one hundred, they do not give the relative fre-
quency among patients at large, for, when the whole num-
ber treated was taken into consideration, it was found to
be more frequent in females.
The youngest recorded was sixteen years, the oldest
sixty-six. The cases taken as a basis for this paper were
arranged in ten decades, beginning at ten years, and it was
found that six and twenty-two hundredths per cent, occurred
in the first, eleven and thirty-three hundredths in the second,
twelve and ten hundredths in the third, eleven and twenty-
five hundredths in the fourth, seven and seventy-seven hun-
dredths in the fifth, and three and sixty-eight hundredths in
the sixth, which shows that its greatest frequency is between
the ages of twenty and fifty, with a slight liability of the
maximum occurring between thirty and forty.
The question of the disease being an acquired or an in-
herited vice is one of unquestionable importance. A careful
study of this point, for a number of years, has led the writer
to believe that pulmonary syphilis in adults is a very com-
mon disease, and that it is due to either an acquired or in-
herited taint, the latter being nearly, if not quite, as frequent
as the former. The ground for the belief that the disease
is frequently inherited is shown by the number of cases in
which it appears in young persons under ten or twenty
years of age, whose chastity can not be doubted, and in
whom no primary symptoms have ever appeared. In op-
position to this view may be urged a primary contagion,
passing unnoticed, or a direct transmission by kissing some
Mohamed, F. A. — Two Cases of Syphilitic Disease of the Lung (early
fibroid). Op. citat., p. 339.
Godhart, J. F. — Syphilitic Disease of the Lung. London, 1874.
Frouenier. — " Gaz. hebd. de med. et de ehir.," 48, 49, 61. Paris,
1875.
Thompson, E. Reginald. — Pulmonary Syphilis. "British Medical
Journal," Aug. 28, 1880.
This disease has been recognized and described from Morgagni's
time to the present. A much more extended bibliography could be ap-
pended, but this is sufficient to show that the lesion has been recog-
nized by eminent pathologists.
116
PORTER: PHTHISIS AND PNEUMONIA, THEIR RELATION TO SYPHILIS. [N. Y. Med. Jouh.,
older infected person ; these are outweighed, however, by
the absence of primary and secondary symptoms.
Dr. John Ferguson, of Toronto, reported a number of
cases * where the disease occurred in young children, and
where, all other treatment having failed, the symptoms
yielded to an anti-syphilitic regime, and where the father,
at a later period, inquired if Lis children's condition could
have been influenced by his having had syphilis.
This is proof positive of the transmission of syphilis
during its latent period from a father to his offspring with-
out the mother showing any signs of the disease. The
latent period of syphilis, which lasts from ten to twenty
years, during which there may or may not be exacerbations,
succeeds to the active state, and usually occupies that period
of life in which the larger number of children are generated,
thus probably accounting for the number of cases where
positive symptoms are present without any evidence of pri-
mary contagion. A positive proof of the occurrence of
this disease in the form of a pneumonia or phthisis may be
found in the fact that these complications yield quickly and
favorably to anti-syphilitic treatment. The larger percent-
age among females, especially among the unmarried and
virtuous, seems to favor inheritance. These views are those
of a clinician and pathologist, and vary considerably from
those advanced by syphilologists. The clinical history of a
case of this character is explained by the pathological lesion,
and vice versa. Whether it be of the acquired or inherited
variety may be in doubt, but inheritance from the father's
side is in keeping with the biblical prophecy of descent
even to the third and fourth generations. The recognition
of syphilis in causing and maintaining disease, especially
when the pulmonary organs are the point of attack, would
indicate that a large number were syphilitic and not tuber-
cular in origin.
In many instances patients have come to the clinic with
the statement that some competent observer had diagnosti-
cated an incipient phthisis, accompanying it with an unfavor-
able prognosis. A careful interrogation usually revealed a
specific taint, however, and, when the syphilitic pneumonia
or phthisis had received anti-syphilitic treatment, they re-
solved, so that to-day these patients would pass the most
critical physical examination. Is there any direct relation
between syphilis and tuberculosis ? Decidedly not, although
clinically and pathologically closely allied, therapeutically
they differ decidedly.
The changes found in the lungs are somewhat similar to
those of tubercular phthisis, and caused Niemeyer to re-
mark : f "It may be difficult to decide whether the lesion be
of a syphilitic origin or not." The lungs may be free, but,
as a rule, they are more or less bound to the chest-walls and
diaphragm by newly formed connective tissue, so that the
pleural space may be completely obliterated. The pleura
itself may vary from one eighth to one half of an inch
(three and one hundred and twenty-five thousandths milli-
metres to three and a half millimetres) in thickness. The
greatest thickening is at the apices. After bisecting the
* Phila. "Med. News," January 17, 1885, p. 66.
\ Niemeyer's " Text-book of Practical Medicine," New York, 1881,
vol. ii, p. 771.
lung the following changes are found : the main lobes, and
often the lobules, are separated by distinct bands of newly
formed fibrillated connective tissue, which is not the case
in a normal lung. The bronchi, particularly the smaller
ones, undergo the same change, while the bronchial glands
are indurated and pigmented ; the latter, however, is only
a coincident lesion. There are numerous cheesy-looking
masses which are recognized by a trained eye as gummy
formations. Their cut surfaces have a sticky feel and a
laminated capsule, which, when they have attained considera-
ble size, is quite distinct. The smaller granules have a simi-
lar appearance, and often look as though they could be
readily shelled out. These neoplasms may vary, botli in
size and shape, sometimes occurring as large as a hen's egg,
and sometimes so small that they look like the miliary tu-
bercle. They may occur in masses forming cheesy-looking
patches, or they may occur in single round and isolated
bodies. These masses are separated by degenerated pneu-
monia or by an interstitial thickening of the pulmonary
substance. The early stage is characterized by a diffuse
interstitial thickening of the pulmonary tissue, often asso-
ciated with a degenerative pneumonia peculiar to this dis-
ease. In the latter stages cavities are not infrequent, and
these are also found in the apex or high in the superior
lobe.
The advanced cases are the ones that are usually found
on the necropsy table, while the earlier types are not infre-
quently associated with intercurrent disease or surgical con-
ditions ; but here the histories are very incomplete, often
being passed without attracting any attention. A striking
illustration of this was found in the diabetic case already
published, where, in looking for a tubercular process, a
typical pulmonary syphilitic lesion was found. These patho-
logical proofs of the apex — rather than the base, and ante-
rior portion of the lung — being the point of invasion are
contrary to the ideas of some previous writers, but it has
been invariably so in all the cases examined by the writer,
both in the post-mortem room and at the clinic. These
facts also explain the physical signs which are so marked
during life, and substantiate their truthfulness. Macrosco-
pically, this lesion is differentiated from the tubercular by
the peculiar cheesy and granular gummy formations which
have a tendency to encapsulation, and look as though they
could be readily shelled out and easily separated from the
surrounding pulmonary tissue.
The microscopic appearances are varied and numerous,
and the first thing that attracts the attention is the exten-
sive new formation of connective tissue. In many places
broad bands are found closely resembling tendon tissue,
and intervening between these tense layers there is a univer-
sal thickening of the pulmonary tissue, which also involves
the vascular walls. The yellow elastic fibers are larger, and
consequently appear more abundant. In many of the cases
there is little or no pigmentation found which can be trace-
able to inorganic substances or to blood. The absence of
the first, of course, is indicative of the fact that the inter-
stitial thickening is not due to the irritation of carbon, iron,
stone, or any of the other inorganic substances, as in the
case of some varieties of fibroid induration. The absence
August 1, 1885.1 PORTER: PHTHISIS AND PNEUMONIA, THEIR RELATION TO SYPHILIS.
117
of blood pigment, on the other hand, is positive proof that
it is not due to chronic congestion or impeded blood flow.
This also dispenses with the idea that the dyspnoea must be
due to the stagnation of the blood.
a.
Fig. 1.
The thickness of the vascular walls varies from one
twelve hundredth of an inch (20-833 m. m. m.) to one two
hundredth (24-999 m. m. m.), but in the majority of the
cases they are one eight hundredth to one six hundredth
of an inch (31-250 m. m. m. to 41-666 m. m. m). (See Fig.
1, a.) In a number of instances the capillaries were seen in
the center of these thickened bands (Fig. 1, x), the walls
of which were thickened independently of the vascular
tissue. When the vessels were distended with blood, as
in Fig. 1, x, the thickness of the tissue intervening be-
tween the lumen of the blood capillary and the wall of the
air-sac could be measured, and was found to be from one
twelve hundredth to one four hundredth of an inch (20-833
to 62-500 ra. m. m.).
This would naturally impede the free and easy inter-
change of gases between the two cavities, and would explain
why the dyspnoea in this disease was so profound.
In addition, the connective tissue presents four charac-
teristics microscopically :
1. Dense bands of white fibrous tissue with few cor-
puscular elements.
2. A less dense tissue studded with numerous small,
round inflammatory corpuscles, having an average diameter
of one one hundredth of an inch (4*166 m. m. m.). At
other points, this same connective tissue was thickly set
with oat-shaped corpuscles one thirteen hundredth of an
inch (19-230 m. m. m.) long and one eight thousandth of
an inch (3-002 m. m. m.) broad.
3. The same inflammatory basement substance, inter-
spersed with round nucleated corpuscles, one forty-five hun-
dredth of an inch (4-166 m. m. m.) in diameter, which, taken
alone, looked not unlike a round-cell sarcoma.
Fig. 3.
4. The thickened bands had a granular and degener-
ated appearance.
In many of the ultimate bronchi there was marked fibroid
thickening, and many of the vesicular spaces were filled
with an inflammatory exudation which presented a variety
of appearances :
1. The air-spaces were filled with red-blood disks, leu-
cocytes, desquamated epithelium, and fibrillated fibrin iden-
tical with that found in the second stage of a lobar pneu-
monia. (Fig. 1, b.)
2. Others were filled with decolorized round cells, as in
gray hepatization of lobar pneumonia. (Fig. 1, c.)
3. Others were filled with large, round, distinctly nucle-
ated epithelium cells, with a diameter varying from one fif-
teen hundredth to one two thousandth. (Fig. l,d.)
4. Others contained a granular degenerating material
which would not stain. (Fig. 1, e.)
The marked feature of this change was that all four con-
ditions were irregularly intermingled as though in each air-
sac it ran its course independently of all the rest, going regu-
larly through the red and gray hepatization ; at this point
degeneration, rather than resolution, set in. The thickened
walls prevent absorption, and the degenerating inflammatory
products probably account for the copious expectoration.
This process is best classed as a degenerative pneumonia
and one peculiar to syphilis. This peculiar pneumonia,
associated as it is with diminished elasticity, and with dila-
tation of the bronchial tubes and loss of resilience on the
part of the lungs, explains the absence of both dry and
moist rales. The dilated and moist condition of the bron-
chi accounts for the absence of sibilant or sonorous sounds
which are so common in the ordinary forms of interstitial
pneumonia. This same condition of affairs accounts for
the absence of the crepitant and subcrepitant rales, because
the walls of the bronchi are not able to approximate each
other and cause the sounds.
118
PORTER: PHTHISIS AND PNEUMONIA,
THEIR RELATION TO SYPHILIS. [N. Y. Med. Jode.,
My opinion has always been that these rales were due to
the opening and shutting of the ultimate bronchi, and a
careful study of the physical signs and of a number of sec-
tions has still further convinced me that this is the way in
which these sounds are produced. But I do not care to say
that this is the only way in which they are produced, as
they are often heard in certain stages of pleuritic inflamma-
tions, and there is no point of diagnosis between the two
that is practical. The pleuritic rale, however, is very much
less frequent.
It is well known that there is no tidal motion to the air
beyond the third division of the bronchi. Beyond this
point the air is changed by diffusion and by an anatomico-
physiological law.
The trachea and bronchi are lined throughout with co-
lumnar ciliated epithelium, and the current of motion pro-
duced by these cilia is from within outward at the periph-
ery of the lumen, while the central column of air is constantly
moving downward.
It is by this action of the epithelium that the major
part, if not the whole, of all inflammatory exudations into
the air-sacs and smaller bronchi are brought up to the larger
bronchi, where they can be influenced by the tidal air.
The mass of sputum is pushed up until it reaches the under
surface of the true vocal cords, where it irritates the periph-
eral sensory filaments of the superior laryngeal nerve, through
which it is reflected back to the cough center, when a deep
inspiration and a spasmodic or complete closure of the
chink of the glottis follow. This is in turn followed by a
forced inspiration with the glottis closed, during which
the glottis opens, allowing a sudden escape of a large quan-
tity of air under a very high pressure. The result of this
is that the mass of sputum is driven through the rima glot-
tidis into the larynx, mouth, or outside world, according to
the force of the inspiratory act. This constitutes what is
known as coughing, and is simply a dislodgment of the con-
tents of the superior portion of the trachea. Irritation of
the peripheral fibers of the pneumogastric in the pleura or
bronchi will produce a dry or hacking cough. A thorough
appreciation of these anatomico-physiological laws and their
application to pathological conditions is absolutely essential
for the selection of proper therapeutic agents.
Professor Thomas E. Satterthwaite first called my atten-
tion to the true value of the ciliated epithelium. The large
gummata have a peculiar laminated, fibro-vascular, connective-
tissue periphery which tends to encapsulate and isolate their
granular centers. The surrounding pulmonary substance is
the seat of a peculiar fibro- and degenerative pneumonia.
The capsules are highly vascular, the small vessels having
thickened walls from hyaline transformation (Fig. 3, d) ; the
center often liquefies, the contents being discharged through
a bronchus, leaving a smooth cavity in the pulmonary tissue.
These cavities may contract and form a cicatricial " pock-
mark," or they may remain stationary for months. On the
other hand, they may ulcerate and extend, so that at the ne-
cropsy we would find small smooth-walled cavities, together
with larger ones with ragged walls, or sometimes with walls
similar to those occurring with a tubercular phthisis.
Throughout lungs affected in this way small miliary
bodies closely resembling miliary tubercle are abundant,
but they are not opaque or transparent. These bodies I
have called miliary gummata. These gummata sometimes
Fig. 3. — Gummy Tubercle showing- Cheesy Center, Fibrillated Con-
nective-Tissue Capsule, and Hyaline Thickening of Blood-Ves-
sels. a, surrounding puimonary tissue ; b, cheesy center ; c, sharply
defined filirillated connective-tissue capsule ; d, thickened capillaries show-
ing hyaline metamorphosis.
coalesce, but at first they are round and isolated. A close
study of these, in comparison with miliary tubercle, shows
that there is a vast difference between the two. The pe-
riphery of the gumma somewhat resembles the adenoid tis-
sue of miliary tubercle, but a high power distinctly shows
that its periphery is composed of concentrically arranged
fibrillated connective tissue in which numerous blood-vessels
ramify. (Fig. 3, b, c.) The walls of these vessels, owing to a
hyaline transformation, are invariably thickened. (Fig. 3, d.)
As a rule, no giant-cells are found in the gumma.
In miliar}7 tubercle the adenoid tissue is more delicate
and less perfectly fibrillated ; it is full of small-round cells
and often contains giant-cells ; the capsules are less vascu-
lar and the blood-vessels do not present the hyaline trans-
formation.
Taking the definition of Ziegler as the standard for mili-
ary tubercle — i. e., " a non-vascular nodule (Knbtchen) which
does not grow beyond a certain size, and which, having at-
tained a certain stage of development, undergoes cheesy
degeneration " — gummy tubercles tend to become encapsu-
lated, miliary to soften and diffuse. Such a striking anal-
ogy between these two forms of tubercles naturally suggests
the following queries :
1. Is not tuberculosis superinduced by syphilis?
2. In the late stages of a syphilitic lung, may we not
also have miliary tuberculosis?
3. Have not gumma tubercles been frequently mistaken
for miliary tubercles ?
The first two must be answered in the negative on ac-
count of the absence of temperature and of the Koch Bacil-
lus tuberculosis. There is, however, no good reason why a
tuberculosis should not be developed on a syphilitic lesion,
but the writer has not found a single instance where the
post mortem has revealed this.
Before answering the next question definitely, more data
are required to prevent confounding the two.
August 1, 1885.] PORTER: PHTHISIS AND PNEUMONIA, THEIR RELATION TO SYPHILIS.
119
The rational signs in many respects resemble those of a
tubercular phthisis. The patients complain of having had
a heavy cold with incomplete recovery, followed by a dry,
hacking cough, or one with an abundant muco-purulent ex-
pectoration. The sputum is either white and frothy or
thick, purulent, and of a greenish or yellow tinge, as in a
true pulmonary tuberculosis. Early haemorrhages are fre-
quent and often copious, while the dyspnoea is an early and
pronounced symptom. Pleuritic pains are common, and
there is often great weakness while the general physique
remains fairly good — in fact, the emaciation is not at all in
proportion to the weakness, and is nothing like that of the
tubercular variety. The skin is warm and moist, but there
is little or no elevation of the bodily temperature. Night-
sweats are frequent and distressing, and the patient com-
plains of cephalalgia and of indefinite and wandering pains
in the bones and tissues, which increase at night. Dyspepsia
and slight jaundice are not infrequent. The urine has a
characteristic pale, limpid appearance, which, together with
the sallow complexion, often leads to the suspicion of a ne-
phritic lesion. The urinary examination is usually negative
unless there happens to be a coincident renal lesion.
Married females abort without any apparent exciting
cause further than the syphilitic taint. Their children, if
born, are often plump, but soon die of marasmus. The first
child is often healthy, but the subsequent children are deli-
cate. Frequently patients complain of sore throat and of
an early loss of hair.
The physical signs are peculiar and diagnostic ; the
respiratory act is labored and all the accessory muscles of
respiration are brought into play, but there is little or no ex-
pansion of the chest. Early in the disease palpation reveals
increased fremitus, but in the advanced cases it is dimin-
ished, owing to the small volume of air entering the lung.
Percussion gives varying degrees of dullness, which is
most marked at the apex but diminishes toward the base.
The percussion-note is dull and of " wooden quality," and
localized areas of dullness are found. Owing to the fact
that small cavities have thin walls and contain considerable
air, the dullness is not so great as would be expected, but,
compared with a sound chest, it is decided.
Auscultation yields most positive and peculiar evidence
when the rational history is taken into consideration. The
inspiratory and expiratory murmurs are prolonged and harsh,
especially the former, with a decided intermission between
the two. Broncho-vesicular breathing is frequent at the apex.
When the amphoric whisper is absent the presence of a cav-
ity is eliminated. As a rule, crepitant and sut crepitant rales
are absent, thus eliminating chronic bronchitis. It is differ-
entiated from asthma by the absence of the sibilant and so-
norous sounds. The vocal resonance is exaggerated over
the consolidated portions. Another very strong and patho-
gnomonic sign is a peculiar pain and oedema of the sternum
and of the tibial crests. Pressure over these regions pro-
duces a very peculiar pain, which is quite intense and accom-
panied by a recoil not easily forgotten when once recog-
nized. Patients often try to avoid giving evidence of this,
but as surely fail as though trying to resist the muscular
reaction to the electric current. A noticeable feature is
that when the sternum is excessively sensitive the tibial
crests are less so, and vice versa. There is no other disease
in which this localized tenderness in oedema of the perios-
teum is met with. It is never found accompanying a true
miliary tuberculosis, but it is exceedingly common in con-
nection with syphilis, and, from this absence in cases of
tuberculosis where the diagnosis was confirmed by the ne-
cropsy and its almost universal presence in cases of syphilis,
it may be regarded as pathognomonic of a specific taint.
In addition to this, it is always found to yield when the
patient is under an anti-syphilitic regime.
The diagnosis is based upon five principal signs and
symptoms :
1. The abundant expectoration without any signs of
softening of the pulmonary tissue.
2. The weak and debilitated condition without marked
emaciation and the good rational history of phthisis.
3. Pronounced dyspnoea without any evidence of a car-
diac or pulmonary obstruction to the circulation.
4. The peculiar pain and the reaction to pressure upon
the sternum and tibial crests.
5. The ready response to treatment is another element
in the diagnosis.
The prognosis depends upon the early recognition and
treatment. Syphilitic phthisis may run a very rapid course,
but, as a rule, it is quite chronic. Dissipation hastens its
progress, especially when alcoholic stimulants are used to
excess.
In treating this affection, the liver should first be freely
acted upon by cathartic doses of calomel or podophyllin,
which in some cases should be frequently repeated. Expe-
rience has shown that the mixed treatment yielded better
results than when mercury or iodide of potassium alone was
used. The combination most successful is one sixteenth of
a grain of the biniodide of mercury, from five to ten grains
of the iodide of ammonium, and ten to twenty grains of the
iodide of potassium in a drachm of the compound tincture
of gentian, three times a day after meals.
Great reliance is placed on the ammonium salt, not per-
haps on account, of its intrinsic action in syphilis, but from
the action which it has in rendering the two others more
soluble, capable of easier absorption and assimilation, and
in increasing their solvent action upon these newly formed
gummatous elements — in fact, its action may be compared
to that of trituration on calomel.
This is, of course, only theoretical, although it was
taught by the late Dr. Van Buren, and may not be in
keeping with the experience of other observers, but there
can be no question of its efficacy in the cases in which it
has been tried. Patients have repeatedly come under ob-
servation in whom one hundred grains of the saturated
solution of the iodide of potassium produced no effect, but
who showed rapid improvement after a free catharsis and a
maximum dose of thirty grains of the combined salts. It
may be argued that recovery under the iodide is no sure
proof of the existence of syphilis, as these drugs only pre-
vent a waste of tissue and thus might retard an ordinary
phthisis. It is, however, pretty generally acknowledged bv
writers on therapeutics that the chief potency of the potas-
120
ST UK 0 IS:
SYPHILIS.
[N. Y. Med. Jocr.,
sium salts and iodine is due to their power of increasing
oxidation. Upon this property our theory of their action
has been based. Turkish and Russian baths are also of
great service. It is quite essential to prescribe expectorants
which will render the inflammatory exudation as watery
and free from mucus as possible, at the same time stimu-
lating the ciliated epithelium - cells, and thus freeing the
air-passages of inflammatory products which tend to de-
compose, act as irritants, and interfere with the aerating
space.
The best of food, air, and a total abstinence from all
forms of dissipation must be insisted upon. The inherited
cases are the more intractable, and will not yield to the
iodide of potassium alone.
The conclusions may be summed up as follows :
1. ^Etiology. — Pulmonary lesions attributable to syphi-
lis are very common, more so in females than in males,
with the maximum number of cases occurring between
thirty and forty years of age ; it is as frequently, if not
more frequently, inherited than acquired.
2. Pathology. — Is most frequent at the apex ; usually
involves both lungs; is a peculiar pneumonic proce — in
the early stages, while later cavities are formed, and it be-
comes phthisical in the sense of progressive consolidation,
followed by softening and the formation of cavities. There
is a strong resemblance, but a positive difference, between
syphilitic and tubercular phthisis, and a positive anatomi-
cal difference between a syphilitic and a miliary tubercle.
3. Symjitoms. — These are peculiar and diagnostic.
4. Diagnosis. — This rests mainly upon the rational his-
tory and physical signs, the extreme dyspnoea, the periosteal
tenderness, and the absence of an increased bodily tempera-
ture.
5. Prognosis. — This depends upon an early recognition
of the trouble.
6. Treatment. — It must be anti-syphilitic to be of any
avail. Many cases are unaffected by iodide of potassium
alone, unless under enormous doses, but a rapid improve-
ment follows upon the use of the biniodide of mercury,
iodide of ammonium, and the iodide of potassium.
In conclusion, thanks must be extended to Dr. George
R. Elliot for his pains in examining the specimens for the
bacilli, to Dr. George G. Van Schaick for the drawings,
and to Dr. E. B. Brunn, one of the laboratory students, for
preparing the specimens and examining for the bacilli.
Note. — In addition to the foregoing, I would like to state that, from
October 1, 1884, to May 15, 1885, I made forty-two necropsies. In
eleven of the cases, or 26-19 per cent., there was, in my opinion, a
syphilitic condition of the lung— either gummata or cavities. Each was
put to the test for the bacilli of tuberculosis, and in every instance they
were found to be absent. The last three of the eleven were also put to
the double test for the bacilli of tuberculosis and those of syphilis, and
in all of them the latter were found in abundance, but none of the for-
mer. One case of the forty-two, or 2'35 per cent., had been diagnosti-
cated as tuberculosis. The sputum was found to contain the bacilli of
tuberculosis, and the diagnosis was confirmed by the necropsy.
102 East Thirty-first Street.
"Bartholow's Materia Medica and Therapeutics" is, we are in-
formed, to be translated into French by Dr. Henri Huchard and Dr.
Lucien Deuian, of Paris.
SYPHILIS.*
By F. R. STURG1S, M. D.,
PROFESSOR OF THE DISEASES OF THE OENITO-URIN ARY ORGANS, AND OF VENE-
REAL DISEASES, IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND
HOSPITAL ; SURGEON TO CHARITY HOSPITAL.
The treatment of this affection should be considered
both constitutionally and locally. In the old routine of con-
stitutional treatment with mercury for one period, succeeded
by another of treatment with the iodide of potassium, the
development of the symptoms was so interfered with that
the surgeon was left in the dark w ith regard to the stage and
tendencies of the disease. This method fully justified Vol-
taire's satire: "The practice of medicine was like the pur-
suit of an imaginary enemy by a blind man armed with a
club." Present methods, however, were not open to such a
criticism.
Syphilis is a complex disease, which runs a definite
course, but which has been subjected to an arbitrary and
misleading classification by its division into the primary,
secondary, and tertiary stages. It would have been better
at the first if it had been divided into the early and the late
periods, making the division, not according to the chrono-
logical order, but according to pathological phenomena;
then the early manifestations would be those where there
was no ulceration, while the appearance of an ulcerating
process would be indicative of the later period.
The train of symptoms in this disease is usually pro-
gressive : first, the chancre and the non-ulcerative lesions of
the skin, followed by the destructive processes, with, once
in a while, cases where the whole course of the disease is
malignant.
In these later cases the chancre becomes phagedenic, and
the ulceration, instead of being macular, is pustular and ulcer-
ating, as in the so-called tertiary stage, with which it should
be classed. There is no specific treatment for this affection.
Although a believer in the use of mercury, I consider its
efficacy dependent upon physiological rather than specific
reasons ; and then we must remember that mercury is not
always indicated in syphilis, and is useful in some condi-
tions, but harmful or useless in others. It should not be
used in the initial stage. As a rule, the primary sore, per
se, is of but slight importance, and is serious only on ac-
count of its sequehe. If it is not complicated by improper
treatment and dirt, and remains free from phagedenic ulcer-
ation and of diphtheritic inflammation, it would get well of
itself without recourse to any treatment, and therefore it is
best to confine ourselves at this stage to the simplest things
possible. Although the books make the diagnosis between
the chancroid and the initial lesion an easy matter, in reality
it is frequently quite difficult, especially in the mixed sore,
where, as is often the case, we have to deal with both the
chancre and the chancroid ; and, until we are quite sure of
the true character of the affection, we should abstain from
the administration of mercury, for in the chancroid it causes
more or less irritation, and is of no benefit to the patient.
Even when the diagnosis of the initial lesion is certain, it is
* Read before the Clinical Society of the New York Post-Graduate
Medical School and Hospital, March 7, 1885.
August 1, 1885.]
STURGTS : SYPHILIS.
121
best not to commence the administration of mercury for
some little time, as it prevents the subsequent development
of the diseftse, and the maculae do not appear at the end
of the sixth to the eighth week, or at the end of the forty-
two davs, and the surgeon is consequently left in doubt as
to the correctness of his diagnosis. Delay in the adminis-
tration of the mercury is not detrimental to the patient's
future progress, and therefore, unless he be married and
rapid healing a necessity, only the simplest treatment for
the initial lesion should be employed. Water, lycopodium
powder, bismuth, or even a piece of cotton or charpie, to
prevent the friction of the mucous surfaces, is all that is
required. When further symptoms develop, however, mer-
cury should be resorted to, and its use should be continued
through each successive stage. The iodide of potassium is
useless at the beginning of the disease, and, in fact, its use
only grew up from an effort to compromise between doing
nothing and the administration of mercury, which, from its
abuse in past years, had fallen into disrepute ; but it can
only be useful as an adjuvant, and not as a substitute.
That form of mercury should be used which is the sim-
plest and which produces the least disturbance in the sys-
tem. The chlorides and the iodides are more apt to pro-
duce toxic symptoms than other forms. It was observed,
during my service in the Charity Hospital, that the patients
who were taking the simple blue pill showed a tendency to
ptyalism after a meal of salt meat, the salt apparently serv-
ing to form the chloride. It is no longer considered ngces-
sary to touch the gums, and any symptoms of its toxic
effects upon the salivary glands, the gastro-intestinal tract,
or other portions of the body, should be avoided, and, before
their appearance, the treatment should be suspended or
changed.
The simplest form of mercury is the blue mass, two
grains of which can be advantageously combined with one
grain of iron or quinine, thereby producing a tonic effect.
In truth, mercury is itself tonic when administered in small
doses, as it increases the number of the red blood-corpus-
cles ; and in syphilis we have to deal with both physical
and mental anaemia, the number of the red corpuscles being
diminished while the number of the white is increased.
Although mercury in small doses increases the richness as
well as the number of the red corpuscles, in large doses, the
effect is quite the opposite. While the administration of
the mercury by the simple blue pill is probably the best,
we must not discard the iodides and the chlorides entirely,
as the former is quite useful in the latter stages of the dis-
ease. Where there is a tendency to ulceration of the throat
the bichloride is of use, but the gastric and salivary symp-
toms must be carefully watched during its administration.
Calomel is a treacherous preparation, for often, when the
patient seems to be doing well under its administration,
there is a sudden and unexpected explosion of hydrar-
gyrismus.
The administration of the mercury should be continued
until the symptoms have entirely disappeared, when it may
be suspended until the development of some fresh compli-
cation; hence the treatment of the affection under consider-
ation is largely on the expectant plan. Relapses often
occur, but, if treatment is immediately resumed, they be-
come milder and milder until they cease entirely and the
patient may be pronounced cured; but whether the disease
is entirely eradicated the future only can decide.
This is not very satisfactory, it is true, but, in the pres-
ent state of our knowledge, nothing more definite can be
stated. If, however, I were to be asked whether the con-
dition was curable, I should reply in the affirmative.
The iodide of potassium should be given, owing to its
prompt action, whenever there is ulceration about the
mouth, nose, throat, or parts of the body where there is
danger of any disfigurement ; but we should not depend
entirely upon this drug to effect the cure, as it is not so
positive or so well borne as the mercury. It will often be
noticed that, when the iodide has been given to promote
cicatrization, while the process will proceed rapidly for a
time it will at last be arrested, and the mercury will have
to be resorted to to complete the process. Small doses of
the iodide are useless, and when it is indicated it should be
given promptly and in increasing doses, until the disap-
pearance of the symptoms or the advent of toxic conditions
compels its abandonment. It is very readily absorbed and
as readily eliminated, and we have no knowledge of its
action which can account for its rapid passage through the
blood. We do know that while a dose of ten or fifteen
grains will do little or no good, one of forty or fifty grains
will be followed by an amelioration of the symptoms; yet
so rapid is the elimination that it is not likely that more
is absorbed in the one case than in the other.
The treatment in skin lesions must be continued until
not only the eruption but the staining has entirely disap-
peared, leaving only the scar, which is indelible, and is one
of the few results of this disease that can not be removed.
The initial lesion sometimes leaves a scar, and atrophy,
with a depression and whitish scar, often occurs after gum-
mous infiltrations, whether in the bone or elsewhere. Some
cases do not tolerate either mercury or the iodide, and this
is notably true of those cases which are phagedenic from
the beginning. Sometimes it is best, owing to the consti-
tutional debility from excesses of various kinds with which
these patients suffer, to institute a tonic and hygienic treat-
ment before having recourse to the mercury or the iodide.
The iodide of iron is especially useful in these cases,
although the citrate and potassio-tartrate are well borne.
Cod-liver oil may also be administered.
Some patients may recover without the use of mercury,
but it is not safe to omit its administration, for we can
never tell how the disease will end. Mercury, too, is our
best remedy for this condition, and it would therefore be
indefensible to withhold it and to subject the patient to
the consequent risk, especially as the dangers from its effects
are less than from the effects of the disease, and the number
of recoveries without the mercurial treatment is too small
to build a theory upon. Besides being given internally,
mercury may be administered by inunction, fumigation,
the bath, subcutaneous injection, and by suppositories.
The results of the inunction are comparatively favorable
and it has the advantage of leaving the stomach for what it
lis intended — namely, food and drinks, and not for drugs' j
122
STUROIS:
SYPHILIS.
[N. Y. Mbd. Jock.,
but is uncleanly, and, while it is used quite extensively
in foreign countries, Americans will not stand it — they
prefer to drench their stomachs rather than soil their
skin for five minutes. The old method was to rub in the
ointment in different parts of the body consecutively, first
the arms, then the legs, and then the back. An objection
to this method is that in delicate skins it will produce an
eczema, and that it soils the linen beyond redemption, so
that in private practice it can scarcely ever be used. A
method which is not so objectionable is, after a hot foot-
bath, to apply the ointment to the soles of the feet ; woolen
stockings should then be worn, and then every step will rub
the ointment in. There is no discomfort, the feet are not
cold, there is no blistering of the skin, and absorption
readily occurs. It should be applied every alternate night
for a week or ten days; then it should be suspended for a
like period. Iodide of potassium should be given when
needed, thus constituting the mixed treatment.
The two remedies combined in the same prescription
are given by some practitioners, but this is not advisable,
as it prevents the increase of one of the ingredients with-
out the increase of the other. It is better to give them
separately — the iodide in the saturated solution, which
contains about three fourths of a grain, or practically one
grain to the minim, largely diluted with an alkaline mineral
water, after meals, never on an empty stomach. The prot-
iodide or the biniodide may be given in pill form.
A mercurial bath may be given once or twice a week,
according to the strength of the patient. Lamps are sold
for this purpose. The patient is placed on a cane-bottomed
chair, stripped, and covered with a blanket, outside of
which is a macintosh. A lamp, having a gutter for water
and a cup containing mercury, is placed under the chair
The patient is left in this vapor until after the mercury is
completely volatilized and he has had an opportunity to
cool off somewhat, when he should be wiped off and put
to bed for two or three hours, as in the Turkish bath. The
best time for the administration of these baths is at night.
The hypodermic administration of mercury is now about
abandoned. When it is employed, a combination of corro-
sive sublimate or of calomel and albumin is used. It is
very inconvenient, however, as it necessitates frequent visits
to the physician, and the pain and discomfort to the patient
are very considerable. In large bodies of men, as in an
army or navy, the first objection would not be applicable,
and the method might be found of use.
The treatment by syphilization remains to be considered.
This method depends upon the same theory as vaccination,
but is subject to the difficulty of the absence of a dilute
virus, and that we are not able to predict the future of the
syphilized person. The most recent prominent advocates
of this theory were Boeck and CEwre, of Christiania.
When Dr. Boeck was in this country, Dr. Bumstead al-
lowed him to use the wards of Charity Hospital for the
demonstration of the theory, and I had an opportunity of
personally observing the method, but I received an unfavora-
ble impression from the start, from the fact that the doctor
made no distinction between the chancroid and the syphi-
litic sore. Both were syphilis to him, while to me they
were two very different things, and so I concluded that
something was "rotten in the state of Denmark." The
method of treatment was extremely disagreeable, and the
fact that many of the patients who were subjected to it ran
away — which was remarkable, as the class that frequent
Charity look upon it as a summer home— attests how much
they must have disliked the application. Three sets of
inoculations were made each time : first, in the right breast,
and from these matter was taken- for another set, which
were called the daughter sores, and then matter was taken
from the last to form the granddaughter set, and then still
another group, called the great-granddaughters, beyond
which he did not go. There were usually six or seven of
these open at a time, and the discomfort was very consid-
erable, so that many said they would rather have the dis-
ease than be subjected to the cure, and left the hospital.
From this circumstance it may perhaps be said that the trial
was not complete, but the non-discrimination between the
chancre and the chancroid would have entirely vitiated the
result.
As at present all diseases are being caused by bacilli,
syphilographers are looking for the discovery of such a cause
for this disease. No tissue is exempt from the inroads of
the disease. When it attacks the eye, the result may be
very serious, and we can not be sure that it will not invade
the deep parts and result in blindness. The earlier eye af-
fections are not so serious as the later, for in this disease
there is a tendency toward resolution, while in the later
affections this tendency docs not exist. Atropine is the great
remedy in syphilitic iritis, and at one time the ophthalmolo-
gists relied upon it alone for the treatment ; this is, how-
ever, a mistake, for, while the mild case of iritis, like the
mild case of syphilis in other tissues, will get well without
recourse to mercury, the surgeon should not submit his
patient to the risk of treatment without this drug. Where
the choroid or the retina is affected, the bichloride is better
than calomel or blue pill. The ulcerative throat lesions are
coincident with those of the skin, and, where the skin is
non-ulcerative, the same is true of the throat. When the
throat is affected, the bichloride is the best preparation for
use; locally, a solution of the nitrate of silver should be ap-
plied for its stimulating and astringent effects. It can not
be said to be caustic, even when applied in the solid stick,
as its action is so superficial. The sulphate of copper may
be used for the same purpose, or the parts may be dusted
with calomel. Iodoform is good, but the odor is so intoler-
able that private patients will not allow it to be used.
The affections of the bones and the nervous system are
pathologically the same as the initial lesion, but the one
tends to resolution while the others do not. When nodes
become soft, resist the temptation to put in the knife, for,
while it is good for an abscess to be opened, it is bad for a
gumma, as it admits the air to the bone and necrosis ensues,
for which operation is hopeless, as no proper sequestrum
is formed. In the affections of the nervous system the
remedy should be given promptly and with a free hand.
The most unpromising cases get well when properly treated,
but the iodide must be given in doses which seem appalling
when compared with those beyond which we were warned
August 1, 1885.]
J A GOBY: OSMIG ACID IN PERIPHERAL NEURALGIAS.
123
never to go when we first began to use this drug. One
ounce per diem, in divided doses, has to be given frequently.
Bumstead reports the case of a patient who took his iodide
ad lib. He became, in fact, an iodide eater. The rule may
be relied upon that no toxic results will occur until the
symptoms yield. The remedy should therefore be carried
to that point and then dropped. Symptoms that laugh at
fifty will yield to one hundred grains, and the necessity for
one hundred and fifty or one hundred and eighty grains
need cause no alarm. Many physicians will refer to fifteen
grains as a large dose, and look incredulous when a dose of
fifty or one hundred is mentioned. All practitioners should
be prepared for the treatment of syphilis, for it often plays
a not unimportant part where not expected, and is an im-
portant factor in the diseases of children. In every depart-
ment of medicine we must be ready to meet it and to expect
a cure.
THE USE OF OSMIC ACID
IN PERIPHERAL NEURALGIAS*
By GEORGE W. JACOBY, M. D.,
PHYSICIAN TO THE CLASS OP NERVOUS DISEASES OF THE GERMAN DISPENSARY
OP THE CITY OP NEW YORK.
When, in 1883, Neuber (G. Neuber, " Ueber Osmimn-
saure-Injectionen bei periphare Neuralgien," " Mittheilungen
aus der chirurgischen Klinik zu Kiel," i) published the re-
sults of the treatment of peripheral neuralgias by hypoder-
mic injections of osmic acid, it was to be foreseen that,
owing to the good results obtained, other observers would
take up the remedy and investigate its action in this regard.
Such an inquiry was all the more necessary as the number
of Neuber's cases was so small. The cases were old and
obstinate ones, and consisted of two cases of sciatica and
■one of trigeminal neuralgia, which were all cured after ten
to twenty-four injections. Only in one case was there a
return of the pain, and this was again relieved by the same
mode of treatment. The treatment of neuralgias is fre-
quently so unsatisfactory that it is well to have at our com-
mand a great many remedies, any of which offer a hope of
success. For this reason it becomes our duty to examine
into remedies which are supposed to exert an influence upon
this affection, whether that remedy a priori seems rational
or not. Notwithstanding the small number of cases detailed
by Neuber, the result attained was so good that Eulenburg
("Die Osmiumsaure-Behandlung bei periphiiren Neural-
gien," " Berliner klinische Wochenschrift," 1884, p. 99)
put the remedy to a fair test. He reports and tabulates
twelve cases upon which he tried the remedy. The nerves
affected were various ones of the upper and lower extremi-
ties of the body and of the head. He chose the fresh and
not extraordinarily severe cases. The duration of treat-
ment varied from one to six weeks, and the number of
injections in the different cases was from three to sixteen.
In a foot-note to his article he says that since then he
has treated seventeen more cases, and of these four were
cured — two sciaticas, one lumbar, and one intercostal neu-
ralgia. The twelve tabulated cases are as follows :
* Read before the American Neurological Association, June 17,
1885.
No.
10
11
12
Sex, age, etc.
35 y., male
machinist.
43 y., male
merchant.
65 y.,
female.
44 v., female
32 y.,
female.
29 y.,
female.
49 y.,
female.
30 y.,
female.
47 y.,
female.
40 y., male,
laborer.
53 y.,
female.
49 y.,
female.
Disease.
Right - sided sciatica ;
fresh case.
Right lumbo-sacral neu-
ralgia (affection of n.
cutan. femor. ext. and
post.), to a slight ex-
tent also left-sided.
Left neuralgia brachia-
lis (" neuritis " of
single arm nerve-
trunks) ; fresh case.
Right sciatica.
(Epilepsy) right brachi-
al neuralgia.
Left trigeminal and oc-
cipital neuralgia.
Left trigeminal (Ramus
u
Bilateral neuralgia of
the (lower) intercostal
nerves ; fresh case.
Left occipital and cer-
vico-brachial ; fresh
case.
Bilateral sciatica ; old
case, recidiv.
Right lumbo-sacral neu-
ralgia ; old case.
Multiple (universal) neu-
ralgias, gouty rheu-
matic basis.
Total
no. of
injec-
tions.
10
4
10
14
Result of treatment.
Cure.
Improvement, but no
cure ; therefore, gal-
vanic treatment em-
ployed.
Cure.
Cure.
Only slight improve-
ment; bromides and
galvanism.
No change ; therefore
change of treatm'nt
No chauge ; therefore
change of treatm'nt
Improvement slight,
result not satisfac-
tory.
Improvement ;
galvanism.
later,
No change ; change of
treatment.
No change ; morphine
injections also had
no effect.
No change ; other
modes of treatment
also without effect.
According to this set of cases, then, the result is not
very encouraging. In twelve cases there were only three
cures, four cases were more or less improved, and five cases
were not influenced at all by the treatment. The three
cured cases were fresh ones; the unaffected ones were old,
complicated or multiple. After this publication I began to
make use of this remedy, and should not now publish my
observations were it not for reports which have since then
appeared, and which certainly show us that we have in
osmic acid a valuable remedy for the treatment of certain
cases of neuralgia.
Dr. A. Wolfler, in a report from the surgical clinic of
Professor Billroth (" Wiener medizinische Wochenschrift,"
1884, p. 1495), reports eight cases, which may be tabulated
as follows :
No.
Sex, age, etc.
Male, 42 y.
Male, 50 y.
Male, 21 y.
Male, 42 y.
F'male,56y,
F'male,62y.
Male, 67 y.
Female.
Disease.
Right sciatica, three
years' standing.
Sciatica, ten years.
Sciatica ; fresh case,
three weeks.
Sciatica, since one
month.
Left sciatica, one year.
Trigeminal neuralgia,
all three branches.
Trigeminal neuralgia.
Trigeminal neuralgia,
Ramus III.
Total
no. of
injec-
tions.
16
6
1
13
2
10
Result of treatment.
Cure ; no relapse af-
ter four months.
Very much improved.
Cure ; no relapse af-
ter three months.
Cured, with exception
of a small painful
point in calf of leg.
Cure.
Cure ; no attack in
four months.
Improvem't ; relapse
after a few months.
Improved; still un-
der treatment.
This report is so encouraging, and in such contrast to
Eulenburg's, that it necessarily requires confirmation by
other observers. Of eight cases reported, we have five
124
JACOBY: OSMIG ACID IN PERIPHERAL NEURALGIAS. [N. Y. Med. Joub.,
cured, one improved but relapsed, one improved very much,
and one improved but still under treatment. In eight cases
not a single absolute failure.
James Merces (" Osmic Acid in Sciatica," " Lancet,"
1885, p. 58) seems to have had just as much success. He
does not give any details of his cases, but says that he has
tried osmic acid in eighteen cases " which have resisted all
other known methods of treatment." The ages of the
patients varied from eighteen to sixty -five. In twelve cases
he gave absolute relief for a period of three weeks, the
patients then leaving the hospital. In these cases the
number of injections varied from one to four. In six he
gave temporary relief.
The manner in which I treated my cases was as follows:
I made use of a 1-per-cent. solution of osmic acid in water,
and of this 0-50 to 1-00, equal to 0-005 or 0-010, of the acid
was injected. In a few cases less was used, but very rarely.
The preparation was that known as osmium tetroxide, OS 04,
commonly known in histological research as osmic acid.
The preparation known as hyperosmic acid, which was used
by Neuber and others, is probably the same. According to
the best treatises on chemistry, such a combination does
not exist, as no mention is made of it. The solution, when
exposed to the light, rapidly becomes decomposed, turning
dark and ultimately quite black. Eulenburg says that it
can nevertheless be used in this condition, but my experi-
ence has convinced me of the contrary. I consider it en-
tirely inactive when in this state. For this reason it should
be dispensed only from a dark bottle, and a small quantity
only ordered at a time. I have never prescribed more than
20-00 of the solution, this quantity serving for about forty
injections. The injections were always made as near as
possible to the point of severest pain and into the con-
nective tissue surrounding the affected nerve. The pain
caused by the injection is in many cases exceedingly severe,
producing a stinging, burning sensation which generally
follows the course of the nerve. This pain, however, rarely
lasts long, generally subsiding after a few seconds. Occa-
sionally, also, local changes are produced, such as swelling
and puttiness over the seat of puncture, and in many cases I
have seen a hard, circumscribed thickening of the skin and
connective tissue produced in consequence of repeated injec-
tions, which only disappeared after days. There is no dis-
coloration produced by the acid except, perhaps, a single
black spot where the needle was introduced. The action
is a purely local one, no constitutional symptoms whatever
being produced. The experiments of Dr. E. Fraenkel
(" Ueber parenchymatose Ueberosmiurasaure-Injectionen,"
"Berliner klin. Wochenschrift," p. 234, 1884) cast some
light upon the action of osmic acid upon living tissues. In
three animals he made injections of a 1-per-cent. aqueous
solution of the acid, injecting 0-50 to 1*00. The point of
injection was, in all three animals, the thigh, as near as possi-
ble to the point of exit of the sciatic nerve through the fora-
men. The number of injections made was, upon the first ani-
mal, four; upon the second, six ; and upon the third, seven.
Upon the second animal after death, which took place
twelve davs after the last injection, and sixteen days after
the first one, the condition found was as follows : Upon re-
moval of the skin, the superficial fascia and the perivascular
and intermuscular connective tissue were found to be the
seat of diffuse black discoloration. The muscles upon the
back of the leg and thigh were atrophied. The sciatic
nerve was found to have retained its normal appearance for
only half a centimetre below its exit from the pelvis. Below
this point it was colored black, imbedded and intimately
adherent to the connective tissue.
This condition is found as far as the knee, from where
the peroneal nerve may be followed as a clear white cord.
Microscopically, the sciatic nerve above the seat of lesion
showed normal fibers. A piece of nerve taken from below
this point showed nerve -fibers distinctly colored black,
their structure being completely retained. The fibers situ-
ated more internally, which were not discolored by the acid,
were mostly changed, the myelin balled up and granular,
and, in another branch, fatty degeneration was noticeable.
In those parts of the muscle which were directly affected
by the acid an exceedingly severe interstitial myositis was
developed. The condition found was, in general terms, a
parenchymatous degeneration of many nerve-fibers, and in
the muscles a parenchymatous inflammation of the con-
tractile substance, with atrophy. It is very interesting in
this experiment to know that osmic acid produces the same
discoloration upon the living nerve-fibers as it does upon
the dead ones. Whether this discoloration can have any
influence upon the action of the nerve can not be answered
until our knowledge of the transmission of nerve-force is
more positive than it now is.
If various branches of a nerve are affected, it is neces-
sary to inject over each painful branch. These cases will,
however, be found to be mostly intractable ones. Certainly
the results are better in those cases in which the pain is
localized over a single branch. The nerves of the skin do
not appear to be at all affected by the injections, and no
amesthetic action was discernible in any of my cases. Of
the cases under my treatment, and of which I have made
notes, I shall only give three in detail. The first two, cor-
responding to Nos. 1 and 2 of the table, are taken as ex-
amples of the mode of treatment. The third, which is No.
8 in the table, is given for reasons which will become evi-
dent when the case is read.
Case I. — A. S., aged twenty-six years. Had been suffering
for two years, and had been under my treatment for a right
sciatica since February, 1883. The pain started from the upper
part of the thigh and radiated downward to the heel. Pain
upon pressure over the entire course of the nerve. The pain
was so intense when he first came to me that he was unable to
sleep at night, and could obtain a little rest only when under
the influence of morphine. After six months' galvanic treat-
ment he felt well enough to discontinue treatment, but, after a
lapse of two weeks, the pain was as severe as ever, and he
again came for relief. This time galvanism, massage, morphine,
and the actual cautery were all tried, but in vain. Thus, six
more months were passed, until I read Eulenburg's article in
the "Berliner klinische Wochenschrift." I then made an injec-
tion parenchymatously over the sciatic nerve, between the tro-
chanter and tuber ischii, injecting half a grain of the solution.
These injections were repeated three times a week. The first
injection was so painful that, notwithstanding all he had already
August 1, 1885.]
J AGO BY: OS MIC ACID IN PERIPHERAL NEURALGIAS.
125
undergone (actual cautery, etc.), he refused to continue the
treatment. The injections were all attended with more or less
pain. After the sixth injection the pain had ameliorated to
such an extent that he was able to sleep the entire night. In-
jections kept up. After the sixteenth he was entirely free, and
has remained so up to date.
Case II. — T. L., male, aged forty-eight years. Came under
treatment in May, 1884. Right sciatica, since six year*. Had un-
dergone, besides the usual modes of treatment, also an operation
for stretching of the sciatic, but all without relief. Injections
were made in the same manner as in the preceding case. The
injections always caused considerable pain, but at no time were
they unendurable. A translation of parts of a very long letter,
written in German and dated April 1, 1885, will give a good
idea of the result attained. He begins: "After I had spent
months at a time in hospitals during the last six years, and had
ultimately sacrificed everything in order to regain my health,
a physician in Newark, after a thorough examination of my
case, gave me the following advice."
The essence of this advice was that, as a last resort, he
should try the osmic-acid injections, for which purpose he was
referred to me. He then goes on to say :
"The result of the two to three weekly injections is a re-
markable one. I can walk very well, but not for a long period
of time. I can sit, lie down, sleep — all without any pain what-
soever; but, on the other hand, I can not stand still. This
causes pain. But I believe that this also will change in time."
This patient received in all twenty injections. He had been
suffering from a sciatica whicli disabled him from performing
any of the necessary acts of life. He could not sleep, he could
not stand, lie could not walk or sit. The only position in which
he enjoyed comparative ease was stretched out upon his back,
and thus he spent the greater part of six years. The result, to
say the least, was certainly encouraging.
Case III. — Female, aged forty-five years. Seen in consulta-
tion April 12, 1884. Left cervico-brachial neuralgia. Princi-
pal seat of pain over the radial in the arm. The pain had ex-
isted for two years, and was probably the result of a periar-
thritis of the shoulder. Every remedy that had been suggested
had been tried, but without result. I recommended a trial of
osmic-acid injection, and made one myself over the musculo-
spiral nerve. I heard nothing more of the case for a fortnight,
the attending physician having promised to continue the sug-
gested plan of treatment. After the lapse of that period of
time, on April 2Gth, the physician called upon me and told me
that the case had progressed favorably until three days prior to
his visit. The pain had gradually decreased, and prospects of
entire recovery were fair.
At the time mentioned he made the sixth injection in the
usual place. The patient complained at once of intense pain
radiating downward into the thumb and forefinger. The pain
at previous injections had been merely nominal. A few hours
after that she called again and said that she had a feeling of
numbness in the first fingers and along the outer border of the
arm. The following morning the physician called upon her
and found a well-marked classic, radial paralysis. The patient
had during the night slept with her arm thrown backward
under her head, and the doctor concluded that he had to deal
with a common case of radial paralysis due to pressure.
To me the case was not so clear. The sudden severe
pain along the course of the radial after the injection, and the
advent of anaesthesia soon after, inclined me to think that
the paralysis was due to the injection itself. This view has
since then been strengthened in my mind through the pub-
lication of Arnozan (" Des nevrites consecutivcs aux injec-
tions hypodermiques d'ether," " Gazette hebdomadaire de
med. et de chirurgie," January 9, 1885).
In this article Arnozan calls attention to the occurrence
of neuritis following hypodermic injections of ether. He
says that in 1881 he accidentally produced paralysis in four
cases after injections of ether. In 1883 he saw another
case together with M. Salvat, and in 1884 M. Charpentier
and M. Barbier published a case of neuritis of the sciatic
due to the same cause. In all he publishes seven cases.
Of these, six are paralyses of the extensors of one or both
hands, due to injections into one or both forearms. The
advent of paralysis was immediately consecutive to the in-
jectiou except in one case, in which the interval between
the last ether injection and the occurrence of the paralysis
was nine days. Frankel, in the article already referred to,
in the clinical part, says of the experiment upon the second
animal : " After the third injection a complete motor and
sensory paralysis of the foot was developed, and upon the
third animal a paresis also occurred."
In the case of our patient a doubt as to the cause of
the paralysis is certainly permissible, especially as the pa-
ralysis was not noticeable until the day after the injection,
and then may have been due to pressure during sleep. But,
in view of these two publications of Arnozan an'd Frankel,
I feel more inclined to ascribe its production to the osmic
acid.
My cases — eighteen in all, including the three already
given — have been tabulated as follows :
No.
Sex, age, etc.
Disease.
Total
no. of
injec-
tions.
Result.
1
Male, 26 y.
Right sciatica, old case.
16
Cure.
2
Male, 48 y.
Right sciatica, old case.
20
Cure.
3
Female,
Left trigeminal, three
3
Improved, but gave
50 y.
years' standing.
up treatment.
4
Female,
Left crural neuralgia,
5
No change.
35 y.
fresh case.
5
Female,
Right brachial neural-
10
Cure.
30 y.
gia, old case.
6
Male, 37 y.
Bilateral sciatica, old
6
No change, examina-
case.
tion of urine, sugar,
diet and opium, re-
lief.
1
Female,
Left trigeminal, old
3
Improved.
60 y.
case.
8
Female,
Cervico-brachial, old
6
None.
45 y.
case.
9
Female,
Cervico-brachial, old
12
Cure.
37 y.
case.
10
Male, 29 y.
Right sciatica, old case.
18
Cure.
11
Male, 33 y.
Left sciatica, fresh
6
No change.
case.
12
Female,
Left cervico-occipital ;
5
No change.
65 y.
also neuralgia of the
ove
III. br. of trigemi-
each
nal.
point.
13
Female,
Occipital neuralgia, ra-
18
Cure.
40 y.
diating pains to the
shoulder and arm,
old case.
14
F'male,45 v.
Right trigeminal, R. I.
4
No change.
15
Male, 30 y.
Right sciatica, fresh
6
No change; afterward
case.
galvanism; relief.
16
Male, 39 y.
Right sciatica, old case.
17
Cure.
17
Male, 37 y.
Left sciatica, old case.
18
Cure.
18
F'male,44y.
Left sciatica, old case.
12
No change.
These cases, then, analyzed, show us, of eighteen cases,
eight cures, two improved, and eight unaffected. Of the
eight cured cases, five were cases of sciatica. All the cured
126
ROBINSON: ANTISEPTIC INHALATIONS.
|N. Y. Mkd. Jock.,
cases, including the sciaticas, were old cases. Of the unim-
proved cases, eight in number, three were fresh cases and
two were old. The case marked 8 can not be counted, and
of 12 and 14 no note is made.
At any rate, it would seem from these cases that the
sciatic nerve is the one which is most impressionable to the
action of this remedy, and that old, inveterate cases present
a greater chance of success than fresh ones. This is con-
trary to Eulenburg's experience, and in my cases may be
misleading, as I used the remedy only exceptionally upon
fresh cases, in the majority of instances using it only as an
ultimum refuffium.
The conclusions justifiable, then, are :
1. We have in osmic acid a remedy which is of service
in the treatment of certain cases of peripheral neuralgias,
and in some cases where every other remedy has failed.
2. Osmic acid is not an anti-neuralgic, its action is very
localized, and it frequently fails where other remedies suc-
ceed.
3. Its employment is in most cases very painful and not
altogether free from danger.
4. In view of Case 8, it is dangerous to implicate a
motor nerve in the injection.
ANTISEPTIC INHALATIONS.
By BEVERLEY ROBINSON, M. D.
( Concluded from page 65.)
In my first trials of antiseptic inhalations I made use of
Kinnicutt's inhaler, which, I believe, was patterned after
that of Roberts. The inhaler I now employ is slightly
modified by Ford from Yeo's inhaler, so that the sponge is
held by two folds of the perforated zinc-wall, instead of
by strings which originally held it in place. I believe the
inhaler, as I am now using it, could be perfected in the fol-
lowing ways: 1. The holes in the zinc-plate to be made
larger, and thus allow the air to pass through the sponge
more freely. 2. The posterior half of the inhaler not to
be perforated at all, but to consist of one uniform piece on
either side. In this way there would be a stronger direct
current through the sponge with each inspiratory effort of
the person inhaling. 3. A double-valve arrangement, to
be placed so as to allow the vapor to pass from the sponge
into the respiratory tract during inspiration, and also to per-
mit the expired air to pass directly out from the inhaler with-
out repassing through the sponge. With these modifica-
tions properly made, I am satisfied, in certain cases, that the
inhaler could be worn almost continuously day and night,
and sometimes with great benefit to the patient. The
general treatment followed by my phthisical patients was :
1. Malt and cod-liver oil. 2. Compound syrup of the hy-
pophosphites. 3. Iron and arsenic. To the use of one of
these mixtures, stimulants, powdered meat, digitalis, and
quinine were occasionally added. Counter-irritation by
means of iodine, Corson's paint (iodine, croton-oil, and
ether), or fly-blisters, was made whenever it seemed indi-
cated. In many cases one of these treatments had already
been faithfully carried out before the patients came under
my care, and ordinarily, I regret to add, with anything but
promising results, in so far, at least, as the rational symp-
toms of disease were concerned. Of course, with respect
to the physical conditions of the lungs previous to the
time when I first saw them I could only form a probable
judgment, and I inferred simply that as the symptoms of
disease had not notably improved, so the alterations of
structure had doubtless not retrograded to any marked de-
gree. In more than one of my patients the inhalation
used (fir-wood oil, combined or not with chloroform) eased
the throat for a long while after using it. In spite of this
ease to the throat, the cough was not always arrested ; still,
the inhalation gave a sort of renewed vigor, and the patient
felt decidedly cheered and encouraged. Sometimes the in-
halation brings on cough, but not even then does it appear
to irritate the throat. Usually the expectoration was ren-
dered much easier; it decreased often in quantity, and, con-
sequently, there was less cough. While using the inhaler
one'of my patients had a slight haemorrhage, and was dis-
posed to believe at first that the inhalation occasioned it.
Later, and in this same patient, the inhalation (creasote
and alcohol) caused no irritation whatever of the throat,
and was worn one hour at a time, and about three or four
hours in the twenty-four. One patient notably gained sev-
eral pounds in weight while using the inhaler, and stated
that he felt stronger and better in every way than he had
previously. When the inhaler was kept on too long, and
in those patients who had functional disturbance already of
the stomach, nausea was occasioned. No inhaling substance
reduced the quantity of sputa to the same extent as turpen-
tine, but this liquid was apt to cause dryness and irritation
of the throat, and was frequently replaced on these accounts
by creasote and alcohol. Not only were the sputa dimin-
ished, as a rule, by inhalation, but several times they
showed manifest changes of color. They also became de-
cidedly less thick and viscid, and, from being green-looking
and tenacious, they soon were foamy, like soap-suds, and
thinner, or showed the aspect of mingled mucus and pus.
The breathing was also improved on many occasions, and
the patient could make more exertion without becoming
flushed and exhausted, or pale and panting. At times the
improvement of breathing, of cough, in the amount and
character of the sputa, in the appetite, in strength and feel-
ing of more lightness and vigor, was accompanied by phys-
ical changes which seemed to indicate improvement in the
local condition at the apex, or apices. In one instance, for
example, I made a note to the effect (and after three
months' use of the inhaler) that the pleuritic rales which
had previously existed at one apex during ordinary respi-
ration had completely disappeared, and the breath-sounds
had otherwise improved. In other words, they had become
more vesicular and less harsh, and the expiratory murmur
less prolonged.
Owing to the diminution of cough and the decrease in
the abundance of the sputa, the patient's sleep was not so
much disturbed — and thus I have found the use of the in-
haler during the evening, and even at bed-time, was evident-
ly a greater promoter of rest than cough-mixtures or ano-
dynes. This was true even when direct examination with
the mirror had shown that the larynx was red, swollen, and
August. 1, 1885.]
ROBINSON: ANTISEPTIC INHALATIONS.
127
inflamed, as indeed evidences were already present of incipi-
ent laryngeal phthisis. One of these patients stated in em-
phatic termsthat, although she had taken all sorts of drugs
for her cough, none of them helped her so much as the in-
halation. I would not have my bearers misunderstand me
and believe I am of the opinion that in the oro-nasal inhaler
we have a panacea for cough and other distressing symp-
toms of phthisis at the first stage. Frequently patients will
do well for a time with one kind of inhalation, and we shall
feel greatly encouraged ; and then, through some exposure
or imprudence, or indeed by reason of the steady on-
ward march of the disease, the cough again grows worse and
other annoying symptoms return with full force — again and
again to be relieved by some new form or combination of
inhalation. In one case I employed at different times and
during many weeks, extending in all over several months, the
following inhalations : At first, inhalations of eucalyptus,
then of carbolic acid, iodine and benzoin, later of creasote
and alcohol, and finally of fir-wood oil, conium, and ben-
zoin. Each one of these relieved for a time, and afterward
lost its beneficial, soothing effect. Still, everything consid-
ered, I concluded I had a means which, contrary to HassaH's
opinion, was powerful for good, and, despite regrettable
failures, was more useful in many instances than steam in-
halations or atomized fluids. In not a single instance was
I satisfied that the metallic inhaler, when properly em-
ployed— and by this I mean when the quantity of fluid
poured upon the sponge and the duration and frequency
of the inhalation were judiciously regulated — increased the
cough except in a very temporary manner, or was productive
of any evident bad results. What I have written in regard
to the effects of inhalation of vapors of antiseptic fluids in
pulmonary phthisis at its first stage is almost, if not equally,
true of phthisis at its second stage, and when the pulmo-
nary apices give undisputable signs of softening and break-
ing down. Even under these circumstances cough becomes
less, expectoration is soon more fluid, and, in consequence,
more readily raised, and the patients speak of diminished
difficulty of breathing and improved rest and sleep at night.
In my cases of fibroid phthisis the patients, after a few
weeks' use of the inhaler, felt much improved. They could
use the inhaler half an hour to an hour at a time, and sev-
eral times a day, without inconvenience, and stated that
they thought the inhalations helped their cough very much.
In these cases, also, the sputa diminished notably in quan-
tity and became more frothy, and lost in great part their
viscid character. From my limited experience with these
cases, I am inclined to believe the fir-wood oil is more useful
as an inhalation than any other liquid employed by me.
In laryngeal phthisis the cough in one instance was more
frequent and troublesome at first ; later it seemed to im-
prove. Certainly the expectoration was looser, although
more abundant, and no unpleasant sensations were experi-
enced while inhaling. In one instance the patient increased
several pounds in weight while under treatment by means
of antiseptic inhalations. No visible changes in the intra-
laryngeal condition were noted, although repeated examina-
tions were made with the mirror to detect, if possible, such
modifications. The inhalation employed in these cases was
a combination of one part of fir-wood oil with four parts of
tincture of benzoin. A point to which I desire to direct
attention in regard to the use of all inhalations is this : Fre-
quently inhalations are useful in allaying cough and the
symptoms dependent upon it, even though it is evident that
the inhalation does not penetrate below, or even so far as,
the larynx. This fact maybe explained in two ways: First,
as is well known, the cough may in reality be occasioned
by a morbid condition in some part of the respiratory tract,
preceding the lungs in location, and although the lungs or
bronchial tubes may also be inflamed. This morbid condi-
tion may be an elongated uvula, post-nasal catarrh, follicular
disease of the pharynx, acute or subacute laryngitis, etc.
Again, in the use of all forms of inhalation, while the sooth-
ing and modifying effects of it are partly due to their direct
local application, still there are similar effects produced by
their absorption by and elimination through the mucous
membrane lining the parts referred to. A final question in
regard to phthisis and antiseptic inhalations should here be
mentioned. Do they destroy the Bacillus^ tuberculosis, or
do they affect notably its growth or vitality? Personally,
I have never searched for tubercle bacilli after the oro-nasal
inhaler had been worn a considerable time, and in which,
previous to wearing it, these characteristic micro-organisms
had been found. In one case, however, a careful micro-
scopic examination of sputa was made by my house phy-
sician when the patient was known to have evident pulmo-
nary phthisis as shown by indisputable physical signs. At
the time the bacilli were first discovered, inhalation of anti-
septic vapors had not been employed. Several months later,
and when during the intervening period a metallic inhaler
had been worn during several hours each day, a second mi-
croscopic examination of the sputa was made and still
showed a large number of bacilli. The precise relative
number of these organisms observed on each occasion is not
mentioned in the history of the patient, nor is it stated
whether there was any proof to show that the bacilli had
less vigor than when first detected. What is known defi-
nitely is this, viz. : that, although bacilli were present in con-
siderable numbers at the time of the second microscopic
examination, the patient herself, both as regards her physical
condition and her rational symptoms, had evidently much
improved. How much the improvement was. directly due
to the use of continuous inhalations it was impossible to
affirm positively. There was no doubt, however, as to the
fact that they had been useful and comforting in allaying
cough, diminishing faucial irritability, and promoting the
ease of expectoration.
If other observers be consulted, I am not aware that, up
to the time of writing, anything more definite can be ob-
tained in regard to the mortuary effects of inhalation on
tubercle bacilli than what I have stated.
Whether or not, therefore, dry-vapor inhalations in c on
centrated form are able to destroy tubercle bacilli is not yet
satisfactorily determined. That they are powerful to arrest
or prevent fermentative and putrefactive changes of the sputa ;
that they can modify the terminal bronchi and lung-cells so
that they will secrete less purulent matter for expectoration —
so much at least results from direct clinical observation and
128
ROBINSON: ANTISEPTIC INHALATIONS.
[N. Y. Med. Jot n.T
experience. It is also highly probable that continuous dry
antiseptic inhalations are able to weaken and partly devi-
talize the infective germs upon which the origin and
growth of pulmonary phthisis largely depend, according
to the present state of our knowledge. The manner in
which this is accomplished is apparently either by direct
action upon these organisms or indirectly by rendering
their surroundings and the location where they are deposit-
ed very unfavorable to their extension or propagation. It
is perhaps true, and it is certainly conceivable — by reason
of analogy with other means by which some organic germs
are killed — that such an effect may be produced by pro-
longed or frequent inhalations of antiseptic volatile agents
of moderate concentration, as well as by shorter inhalations
of very strong vapors. This is a most fortunate circum-
stance, since it is proved that the continuous inhalation of
concentrated vapors of antiseptic substances, in any notable
quantity, is rendered impossible by the intolerance of the
respiratory mucous membrane to their contact.
The power -such inhalations may have will depend, in
my opinion, upon several distinct factors: 1. Upon the form
and efficacy of the inhaler itself. 2. Upon the substance
which is used and its strength. 3. Upon the frequency and
less or greater continuance of the inhalations. 4. Upon
the stage which the pulmonary phthisis has reached, upon
hereditary influences, hygienic surroundings, and individual
vigor of constitution.
Having already taken up much of your time and atten-
tion, I shall be brief in my remarks about my other cases.
In fact, I do not consider those in regard to which I have
preserved notes as sufficiently numerous to warrant any
strong affirmations. Still, as my memory serves me about
several cases of each disease treated by inhalation, in some
particulars at least, I trust that what I may say has more
value than would be apparent but for this prefatory state-
ment.
A. In laryngitis, acute and subacute, antiseptic inhala-
tions are decidedly useful. They quiet irritation, lessen
hoarseness, diminish cough, change the aspect of the in-
flamed mucous membrane, and, in certain cases at least, evi-
dently hasten the disappearance of symptoms and the estab-
lishment of a cure. In one case, in which there were con-
comitant post-nasal catarrh, pharyngitis sicca, and paresis of
the tensors of the vocal cords, producing hoarseness, there
were also^'a red, swollen epiglottis, arytenoid cartilages, and
ventricular bands." In this case there was moderate cough.
Still it persisted and caused much mental distress, despite
various medications internally, and numerous local applica-
tions of pigments, sprays, and powders. One week after
inhalation was begun the cough had disappeared complete-
ly. The larynx was less inflamed, the pharynx was not at
all glazed, there were little or no frothy sputa, and, indeed,
the patient was so far recovered that the remedy was
stopped. This had consisted of ten drops of turpentine,
used in Khraicutt's inhaler, during five minutes every three
hours.
B. In cases of chronic nasal catarrh the following effects
were noted : A singer, having post-nasal catarrh, hyper-
trophy of the turbinated bodies, slight pharyngitis sicca,
and catarrhal laryngitis, secondary to the other affections.
This patient made use of inhalations of pine-needle oil, and
soon remarked that these inhalations rendered the discharges
from her uose, especially anteriorly, very much less. The
breathing also became notably freer. In fact, after two
months' use of the inhaler, she had very slight trouble, if
any, with her anterior nasal cavities. There still remained,
however, some discharge from the naso-pharyngeal cavity.
It is only fair to state that in this case, as well as in my
other cases of catarrh of the nose, I made use, concomitantly,
of other local treatment as an adjunct. Still, by compari-
son between the cases of nasal catarrh in which dry-vapor
inhalations were employed and those in which these inhala-
tions were not used, although other remedies were made
use of, I believe that the inhalations were undoubtedly
beneficial in the manner stated above. In three cases, in
which marked dysphonia was obviously caused by the ca-
tarrhal inflammation of the nose, inhalations of benzoin and
of benzoin and fir-wood oil produced marked benefit to the
voice and general condition of the throat anoVnose. In one
case, where the nasal duct had become obstructed by rea-
son of pituitary hypertrophy, and there was consequent
epiphora, this symptom, among others, was apparently re-
lieved in a measure by inhalations, and the swollen mem-
brane was reduced in thickness.
C. In subacute and chronic bronchitis, inhalations of tinc-
ture of benzoin and fir-wood oil — one part of the latter to
eight parts of the former — after one or several weeks, di-
minished the cough, expectoration, and hoarseness. Iu one
instance the patient stated distinctly that the cough was
stopped by the inhalation. The amount of fluid used was
10 to 15 drops, one or more times during the day, and the
inhalation was repeated ten minutes every three hours.
In a case of chronic dry pleuritis the first few inhala-
tions produced cough, with expectoration. After a time
the patient felt convinced that the inhalation was of benefit
to him. " He coughs less now than formerly, and there is
much less expectoration."
In one case of chronic laryngitis there was decided
improvement after only a few days' treatment.
In my case of paralysis of the tensors of the vocal cords,
and in one also of chronic pharyngitis, decided ameliora-
tion was shown after a time, owing to the use of the per-
forated metallic inhaler.
DISCUSSION.
Dr. F. C. Shattuck, of Boston, said the paper confirmed him
in certain views concerning antiseptic inhalations which were
partly preconceived and partly based upon experience. Some
years ago, when antiseptics first began to be used by inhalation,
he administered them to certain patients. He found carbolic
acid to be very disagreeable ; it was difficult to induce patients
to wear the inhaler containing it. He could not say whether or
not they were of any benefit, but perhaps he employed the in-
halatious too strong, and possibly under other circumstances
the results would have been better. Certainly it was very
desirable to get something which would simply allay cough. If
by means of such simple remedies as these inhalations we could
diminish cough and irritation, we should certainly do our
patients a great service, and the service was no less if it enabled
August i, 1885.J
BOOK NOTICES.
12£
us to dispense, even only to a degree, with the use of opium.
Dr. Hassall's book upon the subject of inhalations was a very
interesting one, but his statement of the case seemed pretty
strong. If one put a few drops of an antiseptic, say of carbolic
acid, thymol, creasote, etc., on a sponge, and found at the end
of two hours' inhalation that three quarters of the remedy could
still be detected in the sponge, certainly the amount of the drug
which could have effected an entrance into the lung must be
very small. That, it would appear, was reasonable ground on
which to distrust this method of treatment. Acting upon these
observations, Dr. Ilassall had constructed his inhalation cham-
ber, and it would be interesting to see what would be the prac-
tical working of it.
Dr. Boardman Reed, of Atlantic City, inquired of Dr. Rob-
inson whether he had used ether or cocaine by this method of
inhalation. It had occurred to him that, inasmuch as these
agents had been found so valuable in other directions, they
might also prove valuable when inhaled in allaying cough, par-
ticularly laryngeal cough.
Dr. P. Kretzsohmak, of Brooklyn, thought the tables re-
ferred to only went to show that there had been a change in
the condition of the sputa after the use of the inhaler.
Dr. B. F. Westbrook, of Brooklyn, thought the benefit
which Dr. Robinson had produced with this mode of treatment
could be referred to two factors: First, the favorable influence
upon the mucous membrane of the upper respiratory tract of an
atmosphere kept constantly at the same temperature. This
every one knew to be a very important matter in irritations of
the respiratory apparatus. It was known that cough, especially
when violent, almost always had its origin in the trachea or above
it, although possibly in the bronchi, and a continuous supply of
uniformly warm, moist air undoubtedly had a very soothing
effect upon this part of the respiratory tract. Besides, balsamic
vapors, which Dr. Robinson had employed, when inhaled even
in very small quantities and for some time, had a very markedly
soothing and beneficial effect upon the irritated membrane. It
seemed to him that the allaying of the nasal and postpharyn-
geal catarrh, the laryngitis, and the bronchitis, would account
for all the good results which Dr. Robinson had observed.
Anything which would give the consumptive rest would in-
crease his appetite, improve sleep, and prove of benefit to his
general bodily condition. Furthermore, Dr. Robinson had
given his patients cod-liver oil, malt, and such agents as would
improve general nutrition. Dr. "Westbrook did not think that
irritation at the apex of the lung would be more likely to pro-
duce cough than irritation of any other portion of the lung. At
least he knew of no proof of it. Dr. Robinson had mentioned
congestion and oedema of the base of the lung as not being
accompanied by cough, but it was also very well known that
pneumonia of the apex was not accompanied by cough, while
the withdrawal of a sufficient amount of pleuritic effusion to
exert considerable influence upon the lung usually led to violent
coughing. He therefore thought it hardly warrantable to say
that irritation at the apex was peculiarly liable to produce
cough.
The President (Dr. A. L. Loomis) remarked that the ele-
ment of cough in phthisis was a very large one, particularly in
the third stage, violent paroxysms occurring as the result of
pleuritic adhesions. One often saw cases in which the only
evidence of phthisis was the presence of fine crepitation at
the apex or some other portion of the lung, and yet the pa-
tient was a sufferer from the most violent paroxysms of cough-
ing, without there being apparent physical signs in the bron-
chial tubes or upper air-passages. His experience with inhala-
tions had led him to believe that they were of use only so far
as they acted as anodynes to the upper air-passages. He, per-
haps, was prejudiced against their use, for his experience with
them had been somewhat unfortunate. Their use had in a few
instances been followed by profuse hemorrhage. He would
not say that the inhalations caused the haemorrhages; he would
only say that two or three cases, occurring at short intervals,
had led him to be careful.
Dr. Robinson, in closing the discussion, said, in reply to Dr.
Reed's question, that on one or more occasions he had used a
small quantity of ether as an inhalation, either alone or com-
bined with balsamic vapors, and he thought it produced some
irritation, although it was very volatile. Certainly ether very
generally produced more or less irritation, and it was but natu-
ral that it should do so in these conditions. He therefore pre-
ferred chloroform to ether. As to cocaine, he had not supposed
that it would be of any benefit inhaled, and had not employed
it. He had, of course, used it as a spray or with the brush in
troubles of the respiratory tract. As to the susceptibility of
the upper portion of the lung to irritation and the production
of cough, of course he could not prove the point positively. He
had concluded, from examination of the sputa in these cases, that
they had come at least as far as from the lung structure, and,
with the physical conditions present, it seemed fair to suppose
that they came from the air-cells. It had been stated in the
discussion that benefit from the inhalations was due to allaying
irritation in the nasal cavities, larynx, pharynx, and trachea.
He too thought that we should seek to know the real source ot
benefit derived from our treatment. He had only stated that
in the use of inhalations we should, as far as possible and with-
out causing undue irritation of the respiratory tract, make the
air inhaled as pure as we could. That was what he had endeav-
ored to do, and he had employed small quantities of the drug
because large amounts caused irritation. If wealthy persons
went to piue regions and to the Adirondacks in search of pure
air, with the expectation of being benefited thereby, it was but
natural to suppose that the poor of New York city would be
benefited by placing themselves in a condition approximating
as nearly as possible the surroundings of such regions. While
he agreed with the president that in a great many cases pleu-
ritic adhesions might be the cause of cough in phthisis, yet his
observation had not led him to believe that they occurred as
frequently as many authorities had stated. He thought the irri-
tation often centered in the lung itself, and was frequently al-
layed by favorable atmospheric conditions reaching the lungs
themselves.
|bok flotices.
BOOKS AND PAMPHLETS RECEIVED.
The Climate of Canada, and its Relations to Life and Health.
By W. H. Kingston, M. D., D. C. L., L. R. C. S. Edin., etc. Mon-
treal : Dawson Brothers, 1884. Pp. 266.
The Middlesex Hospital. Reports of the Medical, Surgical,
and Pathological Registrars, for the Year 1883. London : H.
K. Lewis, 1885. Pp. 544.
Le Peronospora Ferrani, agent infectieux du cholera, et la
vaccination cholerique. Par le Docteur Duhourcau (de Cau-
terets), etc. Avec planche gravee. Toulouse : Edouard Privat,
lb85. Pp. 23.
Cholera and its Relations to State Medicine. By S. Oakley
Van der Poel, M. D., LL. D., etc. New York: The Society of
Medical Jurisprudence and State Medicine, 1885.
Miscellaneous Reprints. By James Craig, M. D., Jersey City,
N. J.
130
LEADING ARTICLES.
IN. Y. Med. Jodb.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Prank P. Foster, M. D.
NEW YORK, SATURDAY, AUGUST 1, 1885.
THE INTERNATIONAL MEDICAL CONGRESS.
"With admirable 8elf-control, the profession refrained until
after the new committee had done its work from giving vent to
the widespread indignation that the action of the American
Medical Association at New Orleans gave'rise to. In the same
issue in which we gave the proceedings of the New Orleans
meeting we sharply rebuked its course in the matter of the
Congress, and shortly afterward the "Journal of the American
Medical Association" characterized it as "of questionable pro-
priety." We insisted at the time that the movement for a
reorganization had its rise in the bitterness of personal disap-
pointments, and not in any genuine feeling that the original
committee had acted otherwise than in the true interest of the
Congress. But, as we have said, the profession at large re-
served its judgment until after the work of the new committee
had been made known, although it had all along been difficult
to see how that committee, practically only a ministerial body,
could accomplish anything in palliation of the destructive course
that had been entered upon at New Orleans. Any lurking hope
of this sort that there may have been was seen to be ground-
less when the results of the Chicago meeting were learned, and
the profession in most of the great cities were prompt to ex-
press their condemnation. So rapidly did the new nominees in
one city after another — Philadelphia, Boston, Baltimore, Wash-
ington, and Cincinnati — declare that they would take no offi-
cial part in the Congress under the new organization that it
became evident that the undertaking was doomed to ignomini-
ous failure unless a complete reversal of the New Orleans ac-
tion could be secured. We have for some time been convinced
that nothing short of that would satisfy the profession and re-
store any reasonable hope for the success of the Congress.- We
have felt, too, that this end was most likely to be accomplished
by getting as full and prompt an expression as possible of the
feelings of the profession. Of late it has looked as if these
withdrawals, which at first threatened to confirm the wreck of
the Congress, would really lead to the radical remedy we have
mentioned, and also to the far more important result of lifting
the American Medical Association out of the low position it
has brought itself to occupy.
The new organization still has its defenders, however. They
are no longer confident, and they have been put on the de-
fensive; but it is evident that they will not give up their un-
dertaking until they are compelled to do so. The tenacity of
their purpose is shown by their latest tactics. Realizing the
effect that is sure to be produced by a continuance of such
-action as that taken in Philadelphia and the other cities that
we have mentioned, and the informal action taken by indi-
viduals elsewhere, they are now trying to persuade those who
have not yet declined not to do so. They hold out the consid-
eration that it is unnecessary and quite out of character for
a man to decline a position until he has been officially notified
of his appointment. As the secretary can take his own time
about notifying the appointees, it is evident that, in case he
avoided sending out notices, and the appointees could be made
to take the advice mentioned, they would have the game in
their own hands. It is nearly a month since the appointments
were made public, and it seems to us that any of the appointees
who hesitate to declare their intentions, simply because they
have not been officially notified, can only be compared to the
man who, seeing a man drowning, refrained from interfering,
on the ground that he had never been introduced to him.
Another device to which they are resorting is that of affect-
ing to look upon the dissatisfaction that has been expressed as
not really due to their revolutionary scheme of reorganization,
but simply to the unpopularity of the secretary, Dr. Shoemaker,
and it is hinted that that gentleman will be induced to resign,
with the result of calling back those who have declined, and
restoring harmony. It is needless to say that nothing could be
more absurd than the pretense that Dr. Shoemaker's unpopu-
larity, in case it exists, is at the bottom of the serious action
that has been taken. It is little short of ridiculous to bring
forward so paltry a matter as being the cause of so important
a step. But, even if there were any truth in it, Dr. Shoemaker
is not the man to allow himself to be cast overboard as a
Jonah. We must conclude, therefore, that the petty nature of
ail that can be said in favor of the reorganization augurs well
for the hopes of those who recognize that nothing but its over-
throw can save the Congress.
DEMAND AND SUPPLY AS APPLIED TO PHYSICIANS.
The constant tendency of our teaching bodies, quite inde-
pendently of the urging that has come from the profession at
large, and the striving of the latter, wholly apart from any
demand on the part of the community, toward improvement in
medical instruction are as gratifying as they are evident. We
believe that within certain limits the matter may safely be left
to these agencies. Therefore we have never looked upon pro-
posed legislative enactments bearing upon it as quite the pana-
ceas that their authors have seemed to believe them. We have
insisted that a uniform standard of the qualification to practice,
whether high or low, was impracticable under existing circum-
stances. If too high, it would reduce the number of practi-
tioners below the force needed in a sparsely settled country; if
too low, it would not meet the fair demands of the older sec-
tions.
That the first of these contingencies is not altogether imagi-
nary is beginning to be found out even in so compact a com-
munity as that of England. The "Medical Times and Gazette,"
of London, lately said : " Assuming for a moment, what might
perhaps claim to be more than a mere assumption, that the
well-meant strictness of the Medical Council is really cutting off
August 1, 1885.]
MINOR PARAGRAPHS.
131
the supply of qualified practitioners in poor and distant neigh-
borhoods, and throwing their inhabitants into the hands of
quacks and herbalists, who is there to warn the Council of this
result? " It is doubtless a. source of annoyance to a man who
has spent all the time and money that could be spent to advan-
tage in attaining to a thorough mastery of the medicine of the
present day to be classed by the community only as one among
little short of a hundred thousand possessors of the degree of
M. D., and it is no less an annoying and humiliating circum-
stance that foreign critics almost invariably hold up our weaker
educational institutions as specimens of what we are able to
produce. All this is inseparable from the young and unde-
veloped state of the country, and it should be endured with
resignation, as a sort of sacrifice to "the greatest good of the
greatest number."
It has often been said to our discredit, and often complained
of by the unsuccessful among us, that the proportion of the
medical body to the population was far in excess of what was
to be found in other countries. We have before expressed the
conviction that this excess had not the same significance that it
would have in a densely peopled country, and we believe that
the great numbers of "young doctors turned out" every year,
as the phrase runs, are not an unmitigated evil.
MINOR PARAGRAPHS.
AN INJUSTICE TO A DISTINGUISHED PHYSICIAN.
The "Medical Times and Gazette" gives a summary of a
statement by Professor Warlomont, of Brussels, a distinguished
ophthalmologist, and a man well known for the energy and in-
genuity he has displayed in the study of animal vaccination, as
well as for his admirable report on the famous Louise Lateau
case. The story was published in the " Presse medicale beige,"
and it sets forth the circumstances of an injustice to which Dr.
Warlomont has been subjected. He has been dismissed arbi-
trarily from the post of director of the Ophthalmological Insti-
tute, the only reason given being the fact that the state of his
health had made it necessary for him to go abroad for a few
months during the past year, for which he had obtained the
permission of the authorities. During the thirty years of his
service he had never before been a week at a time away from
his post. The managers superseded him by abolishing his office.
The pension to which he was entitled was refused him on the
ground that it could only be gained by a person who had at-
tained the age of sixty-five years. He lacks less than a year of
having arrived at that age, and it looks as if his dismissal had
been abruptly and hastily brought about, as our contemporary
intimates, with the intention of depriving him of this acknowl-
edgment of his services.
NEWS ITEMS, ETC.
The Plymouth Epidemic— The memorable epidemic of
typhoid fever at Plymouth, Pa., is now announced to have so
far subsided as to be practically at an end. The relief commit-
tee has discontinued its work, and the hospital was to have been
closed yesterday.
Chicken-pox mistaken for Small-pox. — That unsavory
suburb commonly known as Hunter's Point, but which rejoices
in the high-sounding corporate name of Long Island City, seems
likely to have a suit for damages to defend, according to the
newspapers, as it is alleged that the authorities ordered the re-
moval of a man who seemed to have small-pox to the hospital
on North Brother Island, where it was discovered that he was
only suffering from chicken-pox. He was kept in the hospital
eleven days.
Infectious Diseases in New York.— We are indebted to-
the Sanitary Bureau of the Health Department for the following
statement of cases and deaths reported during the two weeks
ending July 28, 1885 :
DISEASES.
Week ending July 21 .
Week ending July 28.
Cases.
Deaths.
Cases.
Deaths.
1
0
0
1
10
2
16
6
40
14
29
6
Cerebro-spinal meningitis ....
4
3
2
1
48
8
34
8
59
23
34
21
2
0
1
1
The Health of Connecticut.— We learn from the June re-
port of the secretary of the State Board of Health, Dr. C. A.
Lindsley, that the death-rate of ten cities in the State was 16"6
in 1,000, against 18-6 for the month of May. Hartford and
Norwich, however, showed 23-4 and 20-4 respectively. Dr. R.
M. Griswold, of North Manchester, reports an endemic of quinsy,
laryngitis, and bronchitis as manifestations of malarial poison-
ing.
Sir Guyer Hunter is reported, says the " Medical Times
and Gazette," to have been selected as a candidate for a seat in
Parliament.
Army Intelligence.— Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from July 19, 1885, to July 25, 1885 :
Elbeet, F. W., Captain and Assistant Surgeon. Sick leave of
absence further extended four months on surgeon's certifi-
cate of disability. S. O. 162, A. G. O., July 17, 1885.
Strong, Norton, Captain and Assistant Surgeon. Ordered for
temporary field duty with battalion of 8th Cavalry at Hills-
boro, N. M. S. O. 34, Headquarters District of New Mexico,
June 27, 1885.
Everts, Edward, First Lieutenant and Assistant Surgeon.
Ordered for duty as post surgeon, Benicia Barracks, Cal.
Par. 3, S. O. 70, Department of California, July 15, 1885.
(Modifies Par. 2, S. O. 68, 0. S., Department of Cali-
fornia.)
Winne, C. K., Captain and Assistant Surgeon. Ordered for
duty at Benicia Arsenal, Cal. Par. 3, S. O. 70, Department
of California, July 15, 1885. (Modifies Par.'2, S. O. 68, C. S.,
Department of California.)
Society Meetings for the Coming Week :
Monday, August 3d : Utica, N. Y., Medical Library Association ;
St. Albans, Vt., Medical Association; Providence, H. I.,
Medical Association ; Chicago Medical Society.
Tuesday, August 4th : Elmira, N. Y., Academy of Medicine ;
Buffalo, N. Y., Medical and Surgical Association; Ogdens-
burg, N. Y., Medical Association ; Hudson County, N. J.,
Medical Society; Hampden District, Mass., Medical Society
(Springfield) ; Androscoggin County, Me., Medical Associa-
tion (Lewiston).
Thursday, August 6th: Society of Physicians of the Village of
Canandaigua, N. Y.
Saturday, August 8th: Miller's River, Mass., Medical Society.
132
LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES. [N. Y. Med. Jouh.,
f titers io % debitor.
THE INTERNATIONAL MEDICAL CONGRESS.
University op Michigan, July 27, 1885.
To the Editor of the New York Medical Journal:
Sir: Please add our names to the list of those gentlemen
who have already declined to serve as officers in the organiza-
tion of the International Medical Congress as now arranged by
the second enlarged committee of the American Medical Asso-
ciation at their recent meeting in Chicago. In taking this step
we do not intend to criticise the committee for their action.
On the contrary, we think that, handicapped as they were, they
did their work remarkably well. But we do object to the ac-
tion of the American Medical Association at the New Orleans
meeting in introducing into the question of the organization of
a congress for scientific work an element that has no more per-
tinency to such a purpose than the matter of a man's religion
or his politics. Very respectfully, etc.,
E. S. Dunster, M. D.,
Henry Sewall, Ph.D.
THE INTERNATIONAL SANITARY CONFERENCE AND THE
DISINFECTION OF RAGS.
To the Editor of the New York Medical Journal :
Sir: Injustice to ine, I trust that you will publish the fol-
lowing letter, which I have just written to the "New York
Times," in your next issue.
" To the Editor of the 1 Times ' :
"Sir: In your issue of July 22d, under the heading 'The
Importation of Rags,' I find the following:
" ' The frequency with which inaccurate statements have been
made concerning the disinfection of imported rags is somewhat
extraordinary. Several days ago the "Times" called attention
to a letter from Rome, published in a Philadelphia medical
magazine, which purported to give the report agreed to by the
Committee on Disinfection appointed by the International Sani-
tary Conference. The letter in question contained the follow-
ing clause :
" ' " V. Disinfection of merchandise and of the mails is un-
necessary (steam underpressure is the only reliable agent for the
disinfection of rags — les chiffons en gros)."
" ' The " Times " suggested that probably the words were in-
terpolated by the writer of the letter. A few days thereafter
Dr. George M. Sternberg, the American delegate to the confer-
ence, and the same gentleman who was employed as an expert
by Health Officer Smith to make some tests of disinfecting pro-
cesses in Brooklyn, sent a note to the " Times " denying that the
writer of the letter had interpolated the words in question. A
gentleman in this city who is interested in the importation of
paper stock wrote to Dr. Koch at Berlin for definite informa-
tion on this point, and yesterday he received a cablegram stat-
ing that no such words as those quoted in parentheses appear in
the report of the committee.'
"The subscriber has nothing to do with the fight between
the paper manufacturers and the health officers who insist upon
the disinfection of rags from cholera-infected countries, but
must request space in the 'Times' to defend himself from the
grave charge made in the above-quoted paragraph.
" What the gentleman interested in the importation of paper
stock wrote to Dr. Koch I do not know, but that Dr. Koch
should deny that the words referred to are a part of the report
of the Committee on Disinfectants is incomprehensible, and can
only arise from some misunderstanding on his part.
" I inclose herewith a copy of the report of the Committee
on Disinfectants which was printed in Rome and distributed to
all of the members of the Conference. The correspondent of
the Philadelphia medical journal referred to has given a very
good translation of Article V, which in the original is as fol-
lows:
" ' V. La disinfection des marchandises et des colis de poste
est superflu (La vapeur sous pression serait le seul moyen si on
voulait disinfecter les chiffons en gros.)'
"The same wording will be found in the report of the com-
mittee as adopted in proces-verbal No. 10, page 3; also in the
Releve des conclusions, page 16.
"A copy of the proceedings, printed in French and brought
by myself from Rome, is on file in the office of the Hon. T. F.
Bayard, Secretary of State, and another copy in that of the
Surgeon-General, U. S. Army."
George M. Sternberg, Major and Surgeon, U. S. Army,
Delegate to International Sanitary Conference.
fliotcctrings oi £»qu lies,
AMERICAN OPIITHALMOLOGICAL SOCIETY.
Twenty-first Annual Session, held at the Pequot House, New
London, Conn., Wednesday and Thursday, July
15 and 16, 1885.
(Concluded from page 105.)
Two Cases of Congenital Paresis of the External Rectus
were reported by Dr. Harlan, who also exhibited and described
Borek's sphero-cylindrical lenses.
The Removal of a Piece of Steel from the Lens with the
Electro-Magnet. — Dr. J. L. Minor, of New York, reported a
case in which the shank of a strabismus- hook was touched to
an electro-magnet, thus making it a magnet. The extremity of
the hook was then carried into the lens, and the piece of steel
at once attached itself to it and was removed. Thirteen days
later the eye had recovered from the operation. The lens had
not yet been removed.
Removal of an Epithelioma of the Eyelid by Applica-
tions of Benzol and Calomel.— Dr. A. Mathewson, of Brook-
lyn, reported the case of 0. D., a laborer, fifty years of age, who
was seen October 3, 1881, with a tumor on the right lower lid.
This first appeared as a warty growth three years previously.
Of late it had been rapidly growing, and presented a raw granu-
lation surface. Careful examination by an expert showed it to
be undoubted epithelioma. It was treated by frequent dustings
of calomel, after brushing the surface with benzol. The tumor
entirely disappeared until a few months ago, when a granular
spot appeared at one edge of the site of the former growth.
This disappeared under a renewal of the same treatment.
Lipomatous Ptosis.— Dr. H. S. Schell, of Philadelphia, re-
ported four cases of ptosis from excessive accumulation of fat
in the upper lids. The excessive fat was removed through a
horizontal incision. The smallest amount taken away was
thirty-five grains, the largest seventy-one grains. The levator
regained power in from one to four weeks. In one case it was
necessary to repeat the operation.
The Pulsating Variations of Intra-ocular Tension as
measured by the Manometer. — Dr. Luoien Howe, of Buffalo,
N. Y., exhibited the double manometer described by Grasser
and Holzke. In this there was an imperfection in the trocar
August 1, 1885.]
PROCEEDINGS OF SOCIETIES.
133
which was rather complicated and liable to get out of order.
An improvement was accordingly suggested in having a stop-
cock attached to a needle of the hypodermic syringe, and this
the writer found to serve the purpose much better than any
other. The animal best adapted to this class of experiments
was the cat, on account of the deep anterior chamber.
In the earlier experiments with the manometer it was no-
ticed that the intra-ocular tension varied with the heart's
action. In addition to this, the writer called attention to the
fact that these variations in the pressure as indicated by the
manometer corresponded to pulsations which could be seen with
the ophthalmoscope in the vessels in the interior of the animal's
eye. In other words, if the same thing held in the human sub-
ject, we must infer that, when pulsation was seen in the interior
of the eye, there was also a variation of intra-ocular tension,
-although not enough to be detected by the touch or by an ordi-
nary instrument. This connection between pulsation and press-
ure was a demonstration of the cause of venous pulse in the eye
as explained by Bonders. It was also observed that after the
introduction of the needle there was at first considerable pulsa-
tion, but after a short time this ceased, the eye evidently ad-
justing itself to the unusual condition. The experiments re-
ferred to were made in the laboratory of Prof. Zunzt, of Berlin.
The Extraction of Chips of Iron from the Interior of the
Eye. — Dr. H. Knapp reported nine successive cases in which
the electro-magnet was .used for this purpose.
These cases were operated on during the past three years
and a half. In two the chip of iron was located in the iris, in
one for two days, causing inflammation, and in the other for
seventeen years, remaining quiet until receutly. Both were
successfully removed without injury to the eye.
In the seven remaining cases the foreign body was in the
vitreous, had produced cataract, and could not be seen. In
three cases the attempt to extract them with the magnet failed,
and the eyes had to be enucleated. In four cases the chips of
iron were brought forth at the first, second, or third introduc-
tion of the tip of the magnet. In all these four cases the recov-
ery was uninterrupted. All four were still cataractous. In two
the form, size, and tension of the globe were not changed, and
the perception of light was good over the whole field. In the
two others the globe was slightly smaller and softer and the
field of vision defective, corresponding to the wound made for
the extraction of the foreign body. There was no irritation in
any of the four eyes as long as they were under observation.
The Actual Cautery in Destructive Corneal Processes. —
Dr. Knapp cited a number of cases in which its use had been of
service, and he considered it a valuable measure.
Thursday's Proceedings.
Pneumophthalmos, or Air in the Vitreous.— Dr. W. F.
Mittendorf, of New York, reported two cases, the first of which
was that of a young blacksmith who was wounded by a piece
of iron penetrating the sclera and lodging in the vitreous. The
foreign body, surrounded by a clot of blood, was found at the
bottom of the eye. Behind the lens and a little above it, three
air-bubbles were seen by means of the ophthalmoscope. These
appeared to be of the size of a small pea, the smallest about as
large as a rape-seed. They closely resembled the air-bubble as
seen under the microscope, their centers being bright and the
outlines well defined, and surrounded by a sharp, black border.
Their recognition was not difficult. The foreign body could not
be removed with the magnet, and it was decided to allow it to
remain. The eye was carefully bandaged, and the day following
it was found that the air-bubbles had united and were located at
the posterior pole of the lens, the patient having remained
quietly on his back some time before the examination. While
he was in the upright position the air began to rise slowly until
it reached the upper part of the vitreous chamber. During this
trip the bubble looked oval and decidedly pointed at its lower
portion, resembling oil globules as they are seen ascending in
water. Forty-eight hours after the accident every trace of the
air-bubbles had disappeared.
The second case was the result of a drilling accident. Quite
a large piece of stone or iron had perforated the sclera at the
lower and outer part of the eye. In the semi-transparent vitre-
ous an air-bubble of the size of a hemp-seed could be seen dis-
tinctly.
In order to determine the exact appearance of air in the
vitreous, the writer experimented upon rabbits' eyes. Four of
them had air introduced into the vitreous humor by means of a
hypodermic syringe, and four were subjected to the introduction
of oil, also by means of the hypodermic syringe. Nearly all
these experiments were successful. The difference between the
air- and the oil-bubble was so marked that they could be readily
diagnosticated by means of the ophthalmoscope. The latter
were more highly refractive, heavier in appearance, and the
contour decidedly darker than the air-bubbles, which were en-
tirely colorless.
The conclusions reached by the author were as follows: 1.
The entrance of air into the vitreous body could occur only after
a part of the contents of the vitreous chamber had escaped. 2.
It was favored by the entrance of a foreign body, which made a
large, gaping, irregular wound of the sclera. 3. In order to
allow air to enter the vitreous, this must either be quite fluid or
its anatomical arrangement must have been disturbed by the
entrance of a foreign body, or the air must have been attached
to the foreign body and carried with it into the eye. 4. The
air in the vitreous humor appeared like an air-bubble as seen
under the microscope ; it was more or less round, highly refrac-
tive in the center, and had a sharply defined black outline.
5. Oil-globules in the vitreous presented a similar appearance,
but they looked heavier and were not perfectly colorless, and
their outlines were darker; they were also more glittering in the
center. 6. Air-bubbles would be absorbed completely within
two or three days; their presence was not a source of great dan-
ger to the eye. Oil-globules lasted longer, but they were like-
wise non-irritating.
A Case of Tubercle of the Iris.— Dr. Myles Standish, of
Boston, reported the case of a girl, fourteen years of age, who
came under his observation with an eye trouble which had ex-
isted four weeks. There had not been much pain or photo-
phobia. No specific history could be elicited. During the past
winter the patient had suffered with intense epigastric pain and
ascites. The iris was attached by its pupillary margin to the
capsule of the lens, and presented near its ciliary border a
growth 2 mm. in diameter, pink in color, with small vessels on
its surface. In the course of a month the growth had doubled
its size, the conjunctiva and iris remaining perfectly clear.
Other growths made their appearance, and, after consultation
with Dr. Wadsworth, the eye was removed at the Massachusetts
General Hospital. Examination after enucleation show7ed the
vitreous, retina, and choroid to he normal. The lens was some-
what opaque. The iris was very adherent to the capsule of the
lens along its pupillary border, and also beneath the entire area
of the principal growth. The largest mass sprang from the sur-
face of the iris near its ciliary border, and at its base was 2-5
mm. in diameter and 2 mm. in height. At the top its diameter
was 4 mm. This was apparently due to the pressure of the
growth against the cornea. There were three other growths,
but none of them involved the ciliary body, or even the ciliary
border of the iris. The microscopical examination showed the
presence of giant cells and of tubercle bacilli.
134
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jock.,
Dr. Knapp had seen growths presenting exactly the same
appearance which had disappeared under treatment with mer-
cury, even where there was no evidence of syphilis. He had
never felt warranted in making the diagnosis of tuhercle in
such cases, although the presence of the tubercle bacilli in this
case would seem to confirm the diagnosis.
A Case of Congenital Coloboma of the Iris, Choroid,
etc., was reported by Dr. C. J. Kipp. The patient was a woman
sixty-nine years of age. She was first seen four years ago.
There were at that time no inflammatory symptoms, but a small
triangular coloboma of the iris was found exactly in the ver-
tical meridian. The tension was above normal. The patient
had never seen with this eye, but it had never given pain. Four
years later the patient was again seen, and the eye presented
the signs of inflammatory glaucoma. The pain had prevented
sleep for many weeks. The eye was enucleated and healed
promptly. There was also found a large ectasia of the sclerotic,
and over this the choroid and retina were wanting. The ecta-
sia extended close to the optic papule. There was also a deep,
kettle-shaped excavation of the optic nerve.
Coloboma of the Choroid on the Temporal Side.— Dr. S.
D. R islet, of Philadelphia, reported the case of a young physi-
cian who consulted him for asthenopia. There was a consid-
erable degree of myopia in the left eye. In the right eye vision
was much diminished. The ophthalmoscope showed a large
hiatus in the choroid on the temporal side, the depth of which
was 3 D. There had been no pain. The speaker thought that
these cases were comparatively rare.
Gray Degeneration of the Optic Nerve with Abnormal
Patella Tendon Reflex.— Dr. William F. Norris made an
elaborate review of the literature of the subject, and gave the
results of his observations in cases in which the patella tendon
reflex was increased or diminished. He described three cases
of gray degeneration associated with tabes dorsalis which had
come under his observation. While he did not hold that this
symptom indicated beginning tabes dorsalis, yet it was a danger
signal calling for rest of the brain and cord, with attention to
improvement of the general condition.
A Case of Double Optic Neuritis and Ophthalmoplegia
from Lead Poisoning complicated with Typhoid Fever.
— Dr. O. F. Wadsworth reported the case of a boy nine years
of age who had suffered from obscure febrile symptoms for sev-
eral weeks, and movements of the left eye had been observed to
be imperfect. When first seen by Dr. Wadsworth there was
pronounced optic neuritis in both eyes. The rest of the fundus
was normal. Vision was much diminished. No lateral move-
ments of the left eye could be made, and movement downward
was impaired. The outward movement of the right eye was
defective. The probable diagnosis was tumor in the region of
the pons.
The movements of the eyes became still more impaired and
vision sank. The boy developed distinct symptoms of typhoid
fever. The spleen and liver were both enlarged. Lead was
found in the urine, and the diagnosis of tumor was then aban-
doned. The treatment was with iodide of potassium. The gen-
eral condition gradually improved; the neuritis passed into atro-
phy, leaving too little vision to count fingers. The movements
of the eyes were completely restored, and the lead disappeared
from the urine. The cause of the lead-poisoning was found to
be. the presence of a piece of lead pipe in the cistern from which
the drinking water was obtained.
Olive-Oil as a Menstruum for Dissolving Cocaine for
Application to the Eye. — Dr. Joseph A. Andrews said that
the plan of dissolving cocaine in oil seemed to insure a longer
contact of the remedy, and a smaller quantity was required to
effect anaesthesia — two qualities of special advantage in opera-
tions on the eye. Neither the salts of cocaine nor those of
atropine were soluble in olive-oil; but both alkaloids dissolved
readily in the menstruum without the addition of an acid, it
being only necessary to expose the solution for a few minutes
to a gentle heat in a water bath.
Enucleation of the Eye for Glaucoma precipitating
Glaucoma in the other Eye.— Dr. David Webster reported
a case, the patient being a man of fifty-four, the subject of glau-
coma absolutum. He complained of periodical obscurations of
vision in the good eye, and there was no limitation of the visual
field. As he was of dissipated habits, he was advised to live
properly. A week or two later he returned, stating that he had
had a worse attack. There was detected an excavation of the
nerve in the good eye. The glaucomatous eye was now re-
moved. Two days later acute glaucoma appeared. An iridec-
tomy was performed, and he recovered in a week or two, with
no cupping of the disc and no limitation of the field.
Quinine Amaurosis.— Dr. E. Williams reported two cases.
In the first case a man took about one ounce in the course of
four days. This produced total blindness and deafness, but in
six weeks he could see as well as ever. The hearing had never
completely returned, although the quinine was taken eight years
ago. The field of vision was concentrically contracted in both
eyes. The optic discs were very white, the caliber of the ar-
teries and veins was reduced, and the smaller capillaries could
not be seen.
The second case was that of a boy of fourteen, who had
received large doses of quinine, the exact amount not being
known. He was totally blind for four days. When examined,
the sight was much diminished, the atrophy of the optic discs
was extreme, and there was great contraction of the field of
vision.
A Means of Measuring the Amount of Anaesthesia from
Cocaine. — Dr. Lucien Howe exhibited the drawing of a kymo-
graph, which he had used for this purpose. The use of the
instrument was based on the fact that irritation of a sensory
nerve was followed by a rise of blood-pressure. The instru-
ment was connected with an artery, and the conjunctiva was
irritated. Cocaine might then be applied, and the results on
the blood-pressure compared.
Officers for the Ensuing Year.— President, Dr. W. F. Nor-
ris, Philadelphia; Vice-President, Dr. Hasket Derby, Boston;
Secretary and Treasurer, Dr. O. F. Wadsworth, Boston ; Cor-
responding Secretary, Dr. J. S. Prout, Brooklyn.
New Members were elected as follows: Dr. Charles A.
Oliver, Dr. Edward Jackson, and Dr. B. Alexander Randall,
Philadelphia ; Dr. D. Pope Walker and Dr. William 0. Moore,
New York ; Dr. Frank G. Capron, Providence ; Dr. S. M. Bur-
nett, Washington ; and Dr. William T. Bacon, Hartford.
The next meeting will be held at New London, the third
Wednesday in July, 188(3.
CLINICAL SOCIETY OF THE
NEW YORK POST-GRADUATE MEDICAL SCHOOL
AND HOSPITAL.
Meeting of March 7, 1885.
Dr. F. R. Stdrgis in the Chair.
Syphilis. — The Chairman read a paper on this subject.
[See page 120.]
Dr. G. H. Fox did not consider that syphilis was the fright-
ful disease that the text-books would have us believe. He also
thought the results of its treatment by mercury much overrated,
and considered that this drug could be dispensed with without
involving any risk to the patient. The value of a remedy in the
treatment of any special disease could only be determined when
August, 1 1885.1
PROCEEDINGS
OF SOCIETIES.
135
the opportunities of studying the natural history of the trouble
had been taken advantage* of, and he did not believe that this
was the case with the mercurial treatment of syphilis. Many
persons were, too, greatly adverse to mercury, and therefore it
had been the custom for a number of years in the New York
Dispensary to ask the patient if he objected to its use, and if the
reply was in the affirmative, as it often was, they considered
that they were authorized in omitting it altogether, taking the
liberty of thus carrying out an experiment with the consent of
the individual ; and this practice in his hands had been free
from bad results. He considered that the average case of syphi-
lis was benignant in character, and, given average good health,
previous to the inception of the disease, did not believe that it
would produce the ravages ascribed to it. He did not care to
say that mercury was useless in these cases, but thought it was
better to rely upon tonic and bygienic measures than upon the
drug alone, and he felt convinced that many patients recovered
under this mode of treatment. He knew of several old men
who bad undoubtedly contracted the disease in their youth and
who had completely recovered without the intervention of mer-
curial treatment. He also thought that when mercury was used
the dose should be much smaller than the one usually employed,
considering that half a grain of blue mass would accomplish all
that could be gained with one to two grains. The treatment of
syphilis should no more be based upon a routine plan than the
.treatment of scarlet fever, and, just as there were some cases of
the latter affection so mild as to need no treatment, so there
were cases of syphilis that could fall under the same category.
It was absurd, in his opinion, to continue a mercurial treatment
for two or three years in cases that were really so mild that, if
left to themselves, they would end in recovery; but in defer-
ence to custom he usually did continue the treatment for six
months after the symptoms had disappeared. His opinion was,
however, that in the severer forms it was better simply to treat
the symptoms as they arose. In the stage of efflorescence
iodide of potassium had no curative value and should never be
continued for a long period. He considered that great harm
could be done by giving too much of this drug, as several phy-
sicians had reported cases where the symptoms of iodism were
substituted for those of syphilis. Where no good results were
noted from the use of this remedy harm was almost sure to fol-
low, and then it would have been much better had the money
thus thrown away been expended in beefsteak and country air.
Dr. "William H. Portek remarked that his conclusions, de-
duced from both clinical observation and experience in the post-
mortem room, were that, in a very much larger proportion than
was commonly supposed to be the case, of the patients suffering
from diseases of the viscera, an initial syphilitic lesion could be
discovered. This was peculiarly the case with the cerebro-
spinal system, lungs, liver, and kidneys. He was decidedly in
favor of mercury in the treatment of this affection, but did not
consider very large doses of the iodide necessary. It was very
necessary to give calomel or podophyllin frequently, however,
in order to have a free and frequent action upon the liver; he
considered this particularly important in the inherited forms.
He was in favor of combining the mercury and iodide of potas-
sium, and had found that the iodide of ammonium had an effect,
apparently not from any inherent curative power, but because
it seemed to act in very much the same way as trituration did
with calomel, increasing the power of the combined drugs so
that the same result was obtained from smaller doses than
when the ammonium was not employed. lie had obtained
quite as good results from one sixteenth of a grain of the binio-
dide of mercury, fifteen grains of the iodide of potassium, and
five grains of the iodide of ammonium at a dose, when sixty,
eighty, or even one hundred grains of the saturated solution of
the iodide of potassium had failed. If by combining these sub-
stances a small dose would effect the same result as the larger
one, it was of course better.
Dr. G. B. Hope had seen cases of so-called cured syphilis
where the initial lesions had disappeared and the later symp-
toms had been absent for years, but where ulcerations of the
throat and larynx existed of such a character as to be at once
serious and dangerous. These cases yielded more readily to
treatment when internal medication with mercury and the
iodide of potassium rather than topical applications was em-
ployed. He had found that iodoform could be elegantly pre-
pared, and, when combined with morphine powder and used as
a local application, gave great relief.
Dr. D. B. St. J. Roosa remarked that, as his chief interest
lay rather in general medicine and surgery than in the specialty
into which the circumstances of his life had directed him, he
preferred speaking on the subject from that standpoint. He
had been particularly interested in the discussion because it
indicated that the therapeutics of syphilis was approaching a
standard of correctness which was hardly comparable with the
iron-clad notions which formerly obtained regarding the efficacy
of drugs in the treatment of this affection. If it should ever be
his misfortune to be inoculated with this disease, he would pre-
fer to put himself into the hands of a good cook and house-
keeper, with country air and plenty of exercise, to trusting to the
empirical remedies applied by many physicians whom he could
designate. The homoeopathic theory, which considered all dis-
ease a beast, to be hunted out by some other beast, was not
even true in syphilis; neither was it true, on the other hand,
that this affection could be successfully combated without re-
course to drugs of any kind, for was it not apparent to every
one what remarkable results were obtained by the use of iodide
of potassium in the late ulcerations of the fauces and throat?
In ophthalmology, however, if the patients were in an infirm-
ary, where they could have good and nutritious diet and proper
bathing facilities, drugs could be dispensed with, but even then
we should not forget that the character of syphilis differed in
different individuals. The late Dr. Willard Parker had been
accustomed to say, " Study the history of a family before you
say a patient is going to die."
The Chairman would recall the instance of a medical gentle-
man who, troubled with a recurring ulcer of the cornea, had
consulted both of them as to whether or no he had syphilis, and
it was well, perhaps, to remember that we never found this
ulceration in the acquired, although it was very common in the
hereditary form.
Dr. W. O. Mooee said that at the New York Eye and Ear
Infirmary during the past fifteen years one per cent, of all the
eye diseases could be traced to a syphilitic origin. Iritis was
the most common, forty-five per cent, of those inoculated being
affected in this way. Next in the order of frequency was pa-
resis of the ocular muscles, sixty-five per cent, of all these cases
being of a specific origin. The muscles most commonly affected
were those supplied by the third, sixth, fourth, and fifth cranial
nerves. Thirteen per cent, of all the cases of retinitis were
specific. The rarer forms in which this infection exhibited it-
self were: conjunctivitis, nine cases ; ophthalmitis, three cases;'
chancre of the eyelid, two cases; mucous patch of the palpe-
bral conjunctiva, two cases; condyloma of the lid, one case.
Hereditary syphilis was the ^etiological factor in forty-four per
cent, of all the diseases of the cornea, and the clinical fact was
well known that the cornea was not affected by the acquired
variety except through ulceration propagated by contagious in-
flammation, as in mucous patches of the lids ; but in the heredi-
tary variety it was by far the most common eye lesion.
Dr. Culver considered the Turkish bath a very valuable ad-
136
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Joob.,
juvant to mercurial treatment. In Vienna he had seen from
eighteen to twenty-four inunctions effect a cure.
Dr. Porter said that he had never had any personal experi-
ence with the Turkish baths in the treatment of these disorders,
but it was a well-known fact that all syphilitic processes were
removed by increasing the oxidation which consequently caused
the excretory organs to be overworked and their epithelium to
become cloyed, so to speak. He thought the bath would tend
to free them from this effete material, and would be of great aid
to the system generally ; for the same reason he considered free
purgation essential.
Dr. J. M. W. Kitchen had a patient who refused to be
treated with mercury internally, and asked the chairman by
what method it could be applied by the spray.
The Chairman replied that the usual spray was a prepara-
tion of half a grain of the bichloride of mercury to four ounces
of water. This was not irritating, but was not in general use,
astringents being usually preferred.
Dr. W. N. Lesztnsky had used the hypodermic injection of
a solution of the corrosive sublimate in four cases, in doses of
-a thirty-second of a grain, with a little morphine, combined
with glycerin and water. The injections were given in the
mus'cles of the back once daily, and in one case thirty-two, in
another twenty-four, and in the others between twenty and
thirty punctures were made without the occurrence of a single
abscess. In every instance there was some burning pain fol-
lowing the injection, but the discomfort was of but temporary
duration, and in each instance care was had that the injection
should be at least half an inch from the place where the pre-
ceding puncture had been made. In all the cases there was a
clear syphilitic history, and two of the patients, while under ob-
servation, had an eruption, with the fever and headache of the
secondary stage. lie had never found that the iodide disagreed
with an empty stomach, and had been in the habit for some
years of giving it before meals, sometimes, however, dissolving
it in a little milk. Where a tonic treatment was also necessary,
he would give the iodide before and the tonic after meals.
Dr. Charles Henry Brown considered that in by far the
largest number of cases the recoveries from syphilis took place
in the primary or secondary stage, and that only in the minority
of cases did it provoke destruction of tissue and proceed to the
«xhibition of late phenomena. He did not doubt that mauy a
practitioner had seen suspicious sores that were indurated, ac-
companied with swollen inguinal glands and other suspicious
circumstances, but where the history of contagion was absent,
and yet the symptoms were strong enough to lead the ordinary
-observer to diagnosticate the affection and declare that the pa-
tient was suffering with the primary lesions, which diagnosis
would not be doubted until the time for the appearance of the
secondary lesion had passed without the vestige of any cutaneous
blemish.
All writers upon this subject had so emphasized the fact that
the secondary lesions had to appear, that, if for any reason they
did not show themselves, the suspicious sore would be allowed to
pass unchallenged and be considered as simply a local, unimpor-
tant affair. This might or might not be the case, for he consid-
ered that many primary lesions never went beyond the first
stage and were not followed by any secondary phenomena.
The chairman had laid it down as an axiom that the primary
lesion required only local treatment, and that only after the
appearance of the secondary symptoms were we to adopt heroic
treatment. He did not doubt that many of those present had
seen patients run through their secondary syphilide as easily
and as unconcernedly as a child with chicken-pox, provided
they did not know what they had and were in good physical
condition. The vast majority of acute diseases were treated
upon an expectant plan, and we all knew that we could not
compete with Nature's modes of treatment ; in fact, we could
only hope to assist her in her plans. He had been in the habit
for two years past of treating this affection, both in its primary
and in its secondary stages, without recourse to mercury, simply
keeping an eye upon its progress, and when disturbing elements,
such as mucous patches, tonsillar or naso-pharyngeal inflamma-
tions, etc., appeared, he treated them with local applications,
which in the vast majority of cases he found to be quite suffi-
cient. He did not wish to be understood as deprecating the use
of mercury, as he considered it one of the giants of the materia
medica, and thought that it undoubtedly often did all that was
alleged of it, but he was inclined to the belief that its action was
often, in this complaint, confounded with the natural limitation
of the disease. He also objected to the term specific as applied
to the action of drugs, as he thought it implied something mys-
terious and something not fully understood; if it was necessary
to make use of any term, he considered " unknown action " far
preferable. The action of mercury was not, however, unknown,
and its action in syphilis, as the chairman had remarked, was
the same as in any other case. He fully agreed with all this,
but thought that we should not stop without adding that it
failed quite or nearly as often as it was successful. Was it not
possible to call to mind case after case that had not been con-
trolled by mercury ? The severe types of this disease needed
all that Dr. Roosa recommended, and, if possible, even more.
The dietetics and hygiene of syphilis had never received the
attention that they deserved, and yet we had to look in this
direction for the cure of the severe and otherwise unmanage-
able cases oftener than to any other method of treatment. The
use of the Turkish -and Hussian baths, electricity, exercise, and
tonics should be encouraged in every case. The banishment of
syphilophobia, which had as potent a power in retarding recov-
ery as any other agent in the disease, should always engage the
attention of the physician. The drug which the speaker pre-
ferred was iron. If pain, ulceration, etc , complicated the course
of the disease, they should receive local treatment in the shape
of oleates and plasters, and calomel dusted on the surface of
the ulceration. He considered this method of administration
preferable to giving the drug by the stomach, as its action was
exerted directly upon the diseased structure. The late phe-
nomena of syphilis were not so self-limited in duration, and de-
manded more vigorous methods of treatment than the primary,
but care had to be exercised in these cases to improve the con-
stitutional condition, and to place the surroundings in as perfect
a hygienic condition as possible. He did not consider iodide of
potassium capable of exerting any harmful influence upon the
constitution, and, in his experience, although it did not work
rapidly in lesions of the nervous system, it was wonderfully
efficacious in dissipating the late lesions of the disease. Large
doses, however, were essential, and he had frequently seen pa-
tients who took two hundred grains three times a day without
discomfort. In giving such large doses it was necessary that it
should be lavishly diluted, two hundred grains to the pint, and
from fifteen to twenty minutes occupied in its consumption.
Under these circumstances it mattered little whether or not it
was taken on an empty stomach. He had never seen any bad
effect from these doses, unless the patient refused to take a
large amount of water. In the department of nervous diseases
they were not in the habit of looking for much improvement
until the patient reached one-hundred-grain doses. In cases
where there was considerable sclerosis of nerve-tissue the iodide
was alternated with nitrate of silver, and in such cases it was
noticed that when the patients returned to the use of the iodide
the effects were often more marked than in the first instance.
Dr. T. E. Satterthwaite then presented the histories of
August 1, 1885.J
PROCEEDINGS OF SOCIETIES.
137
three cases which illustrated some unusual symptoms following
the internal administration of the iodide of potassium.
Case I. Following the Administration of the Iodide of Potassium
in Moderate Doses. — On March 6, 1882, I was called to see J. C, who
had previously been brought to me through my attendance upon mem-
bers of his family. I found him suffering from agonizing headache,
chiefly of the vortex, and that he had taken large doses of quinine,
which had greatly aggravated the symptoms. It was known to me
that he had acquired syphilis fully twenty-five years before, that he had
contaminated his wife soon after marriage, and that, after many years,
she had only succeeded in bringing into the world a delicate boy, who
had now arrived at maturity, but was phthisical. I had also been in-
formed a number of times previously that he had refused to take anti-
syphilitic remedies, because he disbelieved in doctors and medicines.
In the present extremity, however, he consented to follow out my
recommendations. He was immediately put upon the use of iodide
of potassium, in thirty-grain doses, three times daily. After the third
day an amelioration of the symptoms was noted, and, as the patient
exhibited no phenomena of iodism, the doses were doubled, when
almost immediately coma, with paralysis of the upper and lower ex-
tremities, set in. In fact, all the indications pointed to cerebral com-
pression. The iodide was immediately stopped, consciousness returned,
and with it the paralysis disappeared. With a view of ascertaining
whether the iodide was to be credited with producing these remarkable
conditions, it was again given in drachm doses, and was followed, as
before, by coma, which also disappeared upon the discontinuance of the
drug. The late Dr. J. L. Little saw the case with me in consultation
during both attacks of coma. Under the iodide, in ninety-grain doses,
daily, the patient fully recovered, and was able to resume his occupation.
Case II. — For the notes in this case I am indebted to my friend
and colleague, Dr. Porter. J. N. P., thirty-three, England, contracted
syphilis in 1870, eight years before the present attack. A year later
he married, and his wife subsequently had several miscarriages in suc-
cession. The attack here described occurred in May, 1878, and began
with a severe cephalalgia. On June 3d following he began to be aware
of some paresis of the left side, and had left ptosis. His mental facul-
ties began to deteriorate at the same time. A little later, June 13th,
he was put upon the "mixed treatment," to which the iodide of ammo-
nium was added ; but, showing no improvement, he was given, June
24th, calomel, one forty-eighth of a grain, every fifteen minutes, which
failing, the iodide of potassium, in fifteen-grain doses, was added on
the 29th. Through some mistake it was taken at first every fifteen
minutes, and how long it was continued at these intervals can not be
judged ; but two days later, July 1st, he became comatose, and when
first seen could not be aroused. The pupils were contracted, sensation
over the body was not abolished, the pulse was 80 and strong, and the
respiration was 24. Subsequently the coma lightened slightly, and he
could be aroused when shaken. Later on consciousness returned fully,
and simultaneously there was dilatation of the pupils. As it was not
known that he had taken a large amount of the iodide, it was again
ordered, and was given, presumably, in fifteen-grain doses every fifteen
minutes, in conjunction with the mixed solution before mentioned. On
the following day the patient had another attack of coma, and then
only was it discovered that these extraordinarily large doses had been
given. They were immediately stopped, and the iodide was continued
in moderate and gradually decreasing doses until July 7th. He received
one sixteenth of a grain of the biniodide of mercury, with ninety grains
of the combined potassium salts, six times a day. This amounted to a
dosage of two hundred and eighty grains of the iodide of potassium,
and the same number of grains of the iodide of ammonium per diem.
This was continued without intermission until the 13th, when he was
discharged from the hospital greatly improved. In this instance there
was no renal lesion, nor was the coma attributable to anything but
the potassium salts. It was impossible to determine the amount of
the iodide given daily in this case, but it was evidently more than a
drachm.
These two cases appeared to represent what had been called
by Wunderlich the narcotic symptoms of iodism, among which
he mentioned dizziness, diminution of intellectual power, inco-
herence of ideas, paresis, and even wild delirium, though neither
he nor any other writer, so far as the speaker knew, had ever
fully described the coma of iodism. The nearest approach to
this condition appeared to have been noted by Sir Benjamin
Brodie, who described the paralysis of iodism.
Stille cited the example of a man aged fifty-five under the
treatment of the iodide of potassium where trembling of the
limbs, a feeling like intoxication, an irregularity of motion, and
double vision were experienced. Bumsted and Taylor stated
that sometimes the iodide caused an oppression in the head,
muscular debility, and sluggishness of the intellect. Other
symptoms of iodism had been frequently discussed by writers.
The amount taken appeared not to be a matter of much conse-
quence, for in certain persons and under certain conditions the
iodide would prove poisonous even in very small doses; thus,
Stephen McKenzie had known an infant die of purpura after
taking two grains and a half of the iodide ("British Med. Jour-
nal," 1880, vol. i, p. 626), and the same fact had been noted by
Little (Ibid., April 24, 1880), while Phillips ("Mat, Med.," vol.
i, p. 64) cited a case in which one grain administered to a syphi-
litic patient three times a day produced iodism.
Of a different nature is the following example of profuse
salivation and respiratory embarrassment, following moderate
doses of the iodide :
Case III. — A. J. N., a young man about thirty years of age, con-
sulted me at my office, December 11, 1883. He was then suffering
from supra-orbital, infra-orbital, and maxillary neuralgia, with some
intra-cranial headache. For his relief I gave him morphine, the bro-
mides, and chloral, but the removal of the pain was finally effected only
by large doses of quinine (forty grains a day). In the following month
he developed aphasia, difficulty in articulation of labials and sibilants,
and loss of memory. On January 25, 1884, he was put upon the use
of iodide of potassium, taking twenty minims of the saturated solution
three times a day. Almost immediately he began to complain of a sore
tongue, on which account the medicine was discontinued, but profuse
salivation ensued and continued to the time of his death, February 4th,
coma having set in after an apoplectiform seizure. It may be inferred
that the cerebral symptoms in this case were not due to the iodide,
from the fact that they developed fully a week after the suspension of-
the drug, while it is a matter of general belief, on the other hand, that
these symptoms disappear on the withholding of the drug. It is
equally true in this instance that the soreness of the mouth and saliva-
tion, the coryza, the swelling of the face, and the symptoms of obstruc-
tion of the larynx gained in intensity between the inception and death ;
and it is also noteworthy that the paralysis, at least from mercury, is
not always arrested by the suspension of the remedy. There was also
marked foetor, as in mercurial salivation. The patient had no renal or
cardiac disorder. Dr. J. A. Hegeman, Dr. H. B. McCarroll, and, the
late Dr. J. L. Little saw the case with me, and it was regarded as sin-
gular that the salivation was not arrested, as no mercury had been pre-
viously given. Claude Bernard, after taking iodide of potassium, failed
to find it in the urine twenty-four hours after, while three weeks later
it could be detected in the saliva (Phillips, " Mat. Med.," vol. i, p. 62).
It may have been true, therefore, in this case, as it was agreed in con-
sultation that death was due to causes independent of iodism.
During eighteen years of the practice of medicine, he had
never before seen or known of such a case, although he was
constantly using the iodide, often carrying the dose as high as
six drachms per diem.
Dr. A. A. Altountan said that in Turkey he had seen the
Turkish bath used in the treatment of this affection. It was
usually taken two or three times a week, the patient remaining
in the bath for three or four hours at a time and drinking from
seven to eight pints of water. Sometimes no medicine at al
was used, but mercury was usually administered. Sarsaparilla
also had a great reputation.
(To be concluded.)
138
NEW INVENTIONS.— MISCELLANY.
[N. Y. Med. Jour.,
leto |nbfittions, tit.
A NEW UTERINE APPLICATOR AND DRESSING FORCEPS.
By C. N. Dixon Jones, M. D.,
BROOKLYN.
In certain cases in gynaecological practice the
ordinary methods of cleaning the part and making
application to diseased surfaces have proved so
troublesome that I have devised the following-
described instrument, which has been manufac-
tured by Messrs. George Tiemann & Co., in order
to facilitate the performance of the process.
The instrument is a modification of the well-
known throat applicator devised by my friend
and instructor, the late Dr. Elsberg. It is essen-
tially a forceps provided with a lock similar to the
lock of an obstetrical forceps, in order that the
blades may be separated, to facilitate cleaning.
The method of using the instrument is as fol-
lows : A bit of cotton is rolled into a wad of the
proper size, leaving a firmly twisted projecting
portion, which is grasped between the teeth of
the forceps without springing the blades ; the cot-
ton is then saturated with the appropriate medi-
cament. Thus armed, the instrument is intro-
duced through a speculum and the cotton-point
passed through the os tinea? into the uterine
cavity, and the medicament brought into contact
with the parts to be operated upon.
By using a large wad of cotton, the instrument
may be used to clean the vagina of mucus previous
to intrauterine medication, or for making appli-
cation to the vaginal surface.
After using, the instrument is unlocked, the
blades are separated, the cotton is shaken off, and
the instrument cleaned.
The instrument in my hands has proved itself of great value, and I
can confidently recommend it to the profession.
HI i: s c ft 1 1 a n g .
Recovery after a Fall of nearly Two Hundred and Fifty Feet.
— In the "Bristol Medico-Chirurgical Journal" for June, J. Fenton
Evans, M. B., relates the remarkable case of a girl, twenty-two years
old, who attempted suicide by throwing herself from the Clifton suspen-
sion bridge. After she had partially rallied from the shock, the manu-
brium of the sternum was found dislocated forward, and there were
severe bruises of the buttocks and the back of the thighs. The res-
piration was feeble, and she vomited fluid containing streaks of blood.
Albumin and blood casts appeared in the urine, and there was restless
delirium for several days. In less than three weeks the girl had so
far recovered as to be able to walk without pain, and there appeared to
be no permanent injury beyond slight protrusion at the junction of the
first and second pieces of the sternum. The author adds the following
remarks :
" The height of Clifton Suspension Bridge above the river at low
water is about 250 feet, and the time any weight takes to fall that dis-
tance is about four seconds (leaving the resistance of wind, etc., out of
the question). The time taken by this girl to fall from the bridge was
probably much longer, not only on account of the resistance offered by
the ' rather high wind ' blowing at the time, but also from the nature of
her clothes, which are said to have been inflated from below, and thus
delayed the descent. She was also reported to have fallen on the but-
tocks, which statement was supported by the condition of her clothes
on admission and the bruises subsequently discovered. A point of
some interest is that the patient's memory is now a complete blank as
to what occurred after reaching the bridge, although she can remember
setting out from home with the intention of destroying herself in this
manner. Of the sixteen persons who have hitherto attempted suicide
from this bridge this girl alone has survived the consequences of the
act; one other was picked up alive and survived twenty or thirty min-
utes. As far as the writer knows, no case of survival after a fall from
a height of 150 feet has hitherto been recorded; this instance of recov-
ery, after a fall of nearly 250 feet, is probably unique."
Tyrotoxicon (Cheese Poison).— We are indebted to Dr. Henry B.
Baker, the secretary of the Michigan State Board of Health, for the fol-
lowing abstract of an important paper read by Dr. V. C. Vaughan at
the recent quarterly meeting of the board :
It was well known that eases of severe illness followed the eating of
some cheese. Such instances were of frequent occurrence in the North
German countries and in the United States. In England they were less
frequently observed, while in France, where much cheese was made and
eaten, these cases were said to occur very rarely. A few years ago the
reputation of a large cheese factory in northern Ohio was destroyed by
the great number of cases of alarming illness from eating its cheese.
Dairymen knew this cheese as " sick " cheese.
A German author had said that the numerous kinds of soft cheese
prepared in small families or on small farms were generally the cause of
the symptoms, while it was quite exceptional to hear of symptoms arising
from the use of cheese prepared in large quantities. Some two years
ago a family in Alpene, Michigan, was poisoned by eating cottage
cheese ; the cheese which poisoned so many in the State last year was
made at one of the largest factories in the State, and by an expeiienced
cheese-maker. The old foul-smelling cheeses, such as Limburger and
Schweitzer, had never been known to be poisonous.
The symptoms produced by "sick" cheese, as reported by German
and American physicians, agreed quite closely, and were as follows :
Dryness of the mouth and throat with a sense of constriction, nausea,
vomiting, diarrhoea, headache, sometimes double vision, and marked
nervous prostration. In rare instances the sufferer died from collapse.
As a rule, recovery occurred in a few hours, or at most after a few
days. The symptoms of cheese-poisoning and those of sausage, canned-
meat, and fish-poisoning were very similar, though death resulted more
frequently from the others mentioned than from cheese-poisoning.
The samples of cheese examined had no peculiarities of appearance,
odor, or taste, by which they could be distinguished from good cheese.
It was true that, if two pieces of cheese — one poisonous and the other
wholesome — were offered to a dog or a cat, the animal would select the
good cheese. But this was probably due to an acuteness of the sense
of smell possessed by the animal and not belonging to man. Indeed, if
a person tasted a cheese, knowing that it was poisonous, he might de-
tect a sharpness of taste which would not ordinarily be noticed.
There was no certain means, aside from a chemical examination, by
which a poisonous cheese could be distinguished from a wholesome one.
The most reliable ready method was 'probably that proposed by Dr.
Vaughan a year ago, and it was as follows : Press a small strip of blue
litmus-paper (which can be obtained at any drug-store) against a fresh-
ly cut surface of the cheese. If the paper is reddened instantly and in-
tensely, the cheese may be regarded with suspicion. When treated in
this way, any green cheese would redden the litmus-paper, but ordina-
rily the reddening would be produced slowly and would be slight. If
the piece of cheese was dry, a small bit should be rubbed up with an
equal volume of water, and the paper should then be dipped in the
water. Dr. Vaughan did not regard this test as free from error, but as
the most reliable ready means now known. Every grocervman should
apply this test to each fresh cheese which he cut. The depth of the
reddening of the paper might be compared with that produced by cheese
known to be wholesome.
Dogs and cats, at least, were not affected by eating poisonous
cheese. This was probably due to the fact that they did not get enough
of the poison from the amount of cheese which they ate. The pure
isolated poison, in sufficient doses, would undoubtedly produce upon the
lower animals effects similar to those produced on man.
Dr. Vaughan had succeeded in isolating the poison, to which he had
August 1, 1885.1
MISCELLANY.
139
given the name tyrotoxicon (from two Greek words which meant cheese
and poison). It was a product of slight putrefaction in the cheese,
which probably occurred in the vat, as the curd had been known to
poison a person. By this slight putrefaction, or excessive fermenta-
tion, as it might be called, a large amount of butyric acid was formed,
and this, in the presence of the casein of the cheese, was capable of
developing a poison. Different samples of poisonous cheese contained
different amounts of the poison. The same weight of cheese from one
cake furnished three times as much poison as that from another cake.
The poison was obtained in long, needle-shaped crystals, which were
freely soluble in water, in chloroform, in alcohol, and in ether. The
smallest visible fragment of a crystal placed upon the end of the tongue
caused a sharp, stinging pain at the point of application, and in a few
minutes dryness and constriction of the throat. A slightly larger
amount produced nausea, vomiting, and diarrhoea. The poison was
volatile at the temperature of boiling water, and for this reason even
poisonous cheese might be eaten with impunity after being cooked.
The substance had also a marked pungent odor, and through the nose
one could obtain sufficient of the volatile poison to produce dryness of
the throat. This was true, however, only of the isolated poison. In
the cheese the taste and odor of the poison were both modified to
such an extent that they would not be recognized, as had already been
stated.
The first step in the study of cheese poisoning had now been taken
by finding out what the poison was. Efforts would be made to ascer-
tain the means for preventing its formation.
Small-pox in Michigan. — At the same meeting of the Michigan
State Board of Health at which Dr. Vaughan's report was read, the
secretary submitted a summary of the work done during the quarter
ending July 13th. Small-pox had broken out in several localities,
among them South Haven, where there had been nine cases and one
death. The infection had been brought by a German immigrant who
sailed from Bremen on the 12th of April, on the Donau, of the North
German Lloyd line. He was broken out with small-pox when he
reached South Haven, April 27th, and might have been quarantined en
route. This was another example of outbreaks which a faithfully
executed immigrant inspection service, carried on by the general Gov-
ernment, would put an end to or greatly diminish.
The International Medical Congress and the Profession.— The
" Medical News " publishes the following preamble and resolutions
adopted in Cincinnati :
" Whereas, The recent action of the American Medical Association
with reference to the organization of the proposed International Medi-
cal Congress was, we believe, detrimental to the best interests of the
Congress, therefore,
" Resolved, That we, the undersigned, nominated members of the
Congress, hereby decline to serve."
P. S. Conner, J. C. Reeve,
[Signed.] F. Forcheimer, W. W. Seely,
S. Nickles, J. T. Whittaker,
Thad. A. Reamy, E. Williams.
In addition to the declinations that we have before mentioned, the
"News" announces those of the following-named gentlemen: Dr. J.
Nevins Hyde, of Chicago ; Dr. George M. Sternberg and Dr. R. W.
Shufeldt, of the army; Dr. E. Van de Warker, of Syracuse ; Dr. Will-
iam Lee, of Washington ; and Dr. J. M. Keating and Dr. George E.
De Schweinitz, of Philadelphia.
The same journal publishes the following resolution as having been
passed at the recent annual meeting of the American Ophthalmological
Society :
" Resolved, That it is the sense of the American Ophthalmological
Society that the action of the American Medical Association at its late
meeting in New Orleans, and of the enlarged committee appointed at
that time to make arrangements for the International Medical Congress
in overturning much of the carefully planned work of the original
committee appointed at Washington for the same purpose, was unwise
and not to be defended, unless, possibly, upon technical grounds ; and
this Society hopes that none of its members will indorse the action of
the enlarged committee by accepting official positions at its hands."
The " Pittsburgh Commercial Gazette " publishes the following pre-
ambles and resolutions recently adopted unanimously by the Allegheny
County, Pa., Medical Society :
" Whereas, The American Medical Association, at its recent meeting
at New Orleans, has seen fit to rescind the action of the original com-
mittee adopted at Washington, to arrange for the meet of the Ninth
International Medical Congress, to be held in Washington in 1887, and
" Wliereas, The new committee in its recent action at Chicago has so
changed the arrangements for the meeting of the Congress as to insure
its failure, therefore be it
" Resolved, That the Allegheny County Medical Society disapproves
of the action of the Association at New Orleans and of the action of
the new committee at Chicago ; and further,
" Resolved, That the American Medical Association at its next meet-
ing in St. Louis be advised to restore to the original committee, which
was appointed at Washington, full power to make all the arrangements
for the meeting of the Ninth International Medical Congress."
The Washington Congress in Danger. — Under this heading, the
"Medical Times and Gazette," in its issue of July 18th, says : "Those
who have looked forward to taking part in the next International Medi-
cal Congress, and have counted perhaps on making personal experience
of that friendliness and hospitality of which every English doctor who
has yet crossed the Atlantic has brought back such golden report — yes,
and not only those, but every practitioner to whom the reputation of
his profession is dear — will have read with intense surprise, if not dis-
tress, the intelligence we published last week, that the Washington
Congress is in imminent danger of falling through. We are sorry to
announce that our worst anticipations are in process of realization.
The leading practitioners of Philadelphia, many of whom were to hold
high office in the Congress according to the list distributed by Dr. Bil-
lings some months ago, met together on the 29th ultimo, and decided
that, as the changes recently effected in the preliminary organization
and rules for the International Medical Congress of 1887 'are incon-
sistent with the original plan and detrimental to the interests of the
medical profession in America, and of the International Medical Con-
gress,' they would decline ' to hold any office whatsoever in connection
with the said Congress as now proposed to be organized.' This resolu-
tion was signed by thirty of the most distinguished practitioners in
Philadelphia, including men like Weir Mitchell, Horatio Wood, Roberts
Bartholow, Da Costa, Duhring, Goodell, Minis Hays, Leidy, Pepper, W.
Osier, Still6, Tyson, and Yandell. We hear that a similar movement is
on foot in Boston, and that it is quite likely that the most distinguished
practitioners in that hub of the universe will follow the lead of their
Philadelphian confreres. And as some of the leading New York men,
including Dr. Jacobi and Dr. Lefferts, who were to have presided over
sections, have already been deposed from their places, as adherents of
the New Code, while Dr. Bowditch, the most respected physician of
Massachusetts, has been struck off the list of vice-presidents for his
sympathy with that party, it must be admitted that the ' New York
Medical Journal ' is probably right in describing the outlook for the
Congress as ' gloomy.' We can only hope that the sound sense for
which our American cousins are so distinguished will prevail, and that
the decisive action of the Philadelphia practitioners will rouse the mass
of the profession in America to step in and to decide by overwhelming
numbers before it is too late that old controversies shall be sunk,
that old ill-feeling shall be buried, and that no one shall be allowed
to turn partisan spirit into a ladder for his own elevation at the ex-
pense of the reputation and good fellowship of the profession to which
he belongs.
"We do not wish, and we hope no one on this side the Atlantic will
attempt, to revive the memories of the celebrated dispute on the Codes.
We believe that the late Dr. Panum, the lamented President of the
Copenhagen Congress, distinctly insisted, when the invitation to Amer-
ica was accepted, that the code question should not be raised; and we
feel sure that a very large majority of English and Continental practi-
tioners will refuse to cross the water if this understanding is not rigidly
kept to. They will feel, too, that if they go to Washington they can
only go as the guests of an undivided profession. A Congress from
1 which the most distinguished representatives of American medicine
140
MISCELLANY.
[N. Y. Med. Jotm.
were excluded or had withdrawn would not be worth going to as a sci-
entific meeting, while the remembrance of the bitterness and heart-
burnings which had attended its organization would rob its social dis-
tractions of all their charm. It would be like feasting with a man,
while his wife, unjustly divorced, stood in the street watching. We can
assure our American readers that in the present case the best English
sympathies will be with the wife. The men whom English visitors, if
they go, will go to see and hear are the very men who have been
elbowed out of the Congress. The scientific success of a Congress does
not depend on numbers, but on quality. The profession in America is
no doubt rich in numbers, as well as in scientific activity, but it is not
so rich that it can afford to play all Europe with only pawns on its side
of the board.
" We must add a few lines to explain to English readers how the
matter lies. The American Medical Association, a body which includes
some three thousand of the forty thousand practitioners in the States,
appointed a committee of seven to go to Copenhagen in order to ex-
press the desire of the Association that the Congress of 1887 should be
held at Washington. The invitation was given in the name of the
whole American profession, the Association acting to this extent as its
spokesman. It was accepted, and the committee were intrusted with
full powers to organize and appoint officers of the Congress. They
thereupon added to their original numbers some score of the leading
practitioners of the States, and issued the programme which has been
distributed far and wide. At a recent meeting of the American Medi-
cal Association at New Orleans, Dr. Billings reported on behalf of the
committee, but a certain section refused to accept the work done, and
claimed that the Association had power to revise it, inasmuch as the
committee derived its commission from that body. They succeeded in
getting a majority to indorse this claim, and induced the Association to
strike off the names that had been added to the committee and to re-
place them by thirty-eight new men, elected with regard rather to their
local distribution than to their scientific attainments. The new com-
mittee accordingly, with the exception of the original seven, contains
scarcely a name that is familiar to English ears. The question of the
competency of the Association to act as it had done was submitted to
counsel, with the result that it was declared to have acted quite within
its powers. The members of the original committee therefore decided
to attend the meeting of the enlarged committee held on June 24th and
25th at Chicago, the reports of which have just reached us.
" At this meeting Dr. Beverley Cole, of San Francisco, was elected
permanent chairman of the Organizing Committee, and Dr. Shoemaker,
whose name is familiar to us as the active advocate of the use of the
oleates known by his name, it% permanent secretary. A sub-committee
was appointed to revise the rules and preliminary organization of the
Congress, published at Washington 'in 1884, and their report and list
of officers was subsequently adopted by the committee. The rules,
however, have not yet been published, and we can only say that the
first rule was so amended by the committee as to guard against the
participation of irregular practitioners in the meetings of the Congress.
Besides this, the committee removed from their positions in the Con-
gress some twenty-five men, including Jacobi, Loomis, and Lefferts, who
have given up the code of the American Medical Association and re-
tired from that body, but who are still met in consultation by the ' old-
coders,' and are members of the New York Academy of Medicine.
The committee also entirely changed the executive personnel, substitut-
ing for men whose names are household words with us others whose
reputation has certainly not yet crossed the Atlantic, whatever it may
do in the future. It also removed the chairmen of sections from mem-
bership in the executive committee, and restricted the membership of
the Congress, so far as regards America, to members of the Associa-
tion or of State and County societies in affiliation with it, and to others
nominated by the executive. After these achievements the committee
adjourned to meet in St. Louis just before the next meeting of the As-
sociation. The above is a very brief abstract of intelligence derived
from the American journals and from our correspondents in the States,
and, no doubt, from its very brevity, it will appear somewhat confusing
to the English reader. The whole affair will look to him, perhaps,
very much like a storm in a teapot. He will perhaps, however, be able
to realize the dispute a little more clearly if he can imagine the Com-
mittee of Council of the British Medical Association having taken the
London Congress of 1881 under its entire control, removed all but a
few of the leading London men from any share in organizing the meet-
ing, and allowed no one to participate in the Congress but members of
the Association. But even that comparison would be misleading, for
the English Association represents at least fifty per cent, of the English
profession, while the American Association only contains some seven
per cent, of American practitioners."
The "Lancet" on the Congress. — In its issue for July 18th the
" Lancet " says :
" The Committee of the American Medical Association, appointed
to nominate the list of officers and make the arrangements for the Con-
gress which is to meet in Washington in 1887, has made a preliminary
report. It confirms the nomination of Dr. Austin Flint for the post of
president. This, we imagine, was never for a moment doubtful, and,
as the success of the Congress depends in no small measure upon its
president, we are glad to know that this element of success will not be
wanting at the Washington meeting. Among the vice-presidents we
find the name of Dr. E. Oliver Wendell Holmes [sic]. We trust some
arrangement will be made for him to give an address at the meeting.
The Secretary-General is Dr. John Packard, of Philadelphia, and Prof.
F. S. Dennis is nominated chairman of the Finance Committee ; these
also are excellent nominations. The scientific work of the Congress
will be conducted in sixteen sections, one of which will devote attention
to the work of Collective Investigation."
[When the foregoing was written the " Lancet " was of course not
aware that Dr. Packard and Dr. Holmes had declined to serve.]
The Merritt H. Cash Prize. — The chairman of the Prize Essay
Committee of the Medical Society of the State of New York, Dr. W. W.
Potter, of Buffalo, writes to us that the committee desires to state that
the society offers a prize of one hundred dollars, payable out of the
Merritt H. Cash prize fund, for the best original essay on any medical
or surgical subject. The conditions are: That the competitors shall
reside in the State of New York ; that all essays offered shall be either
printed or type-written ; that each essay shall be designated by a motto
on the titie-page ; that in a sealed envelope, attached to the essay, shall
be placed the name of the writer and the corresponding motto ; and
that all essays shall be sent to the chairman on or before January 1,
1886. Dr. Potter's address is 306 Franklin Street, Buffalo.
Dr. Homans's Laparotomies. — Dr. Homans, of Boston, informs us
that, in our summary of the paper he lately read before the Massachu-
setts Medical Society, we were in error in stating the number of his
laparotomies as two hundred and seven, the real number being two-
hundred and seventy.
The British Gynaecological Society. — Dr. R. Stansbury Sutton, of
Pittsburgh, Pa., and Dr. F. C. Batchelor, of New York, have been
elected to fellowship in the society.
THERAPEUTICAL NOTES.
Coniine in the Treatment of Cough. — The " Centralblatt fur die
gesammte Therapie " publishes the following formula :
Coniine hydrobromate, ) each 15 grains;
Sugar of milk, )
Mucilage of gum arabic, a sufficient quantity.
Divide into forty pills, from two to four of which are to be given
daily for nocturnal convulsive cough.
Potassium Iodide for the Prevention of Habitual Abortion. — Gosh-
kevich (" Wratsch ; " " Brit. Med. Jour.,") remarks that, although the
causes of habitual abortion are obscure, syphilis is the best known of
them, and on that ground, notwithstanding the general belief that
potassium iodide tends to cause abortion, he advises its employment
even when no syphilitic manifestations have been recognized. He
gives two cases to sustain his position. The foetal heart-sounds and
movements, which had become almost imperceptible, improved under
the use of five grains three times a day, and diminished whenever the
administration of the drug was stopped. In each case the full period
of gestation was completed.
THE NEW YORK MEDICAL JOURNAL, August 8, 1885.
£ it tares anfc ^irbr esses.
LECTURES ON
ELECTRICITY IN MEDICINE,
DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI-
VERSITY OF VERMONT, BURLINGTON,
By AMBROSE L. RANNEY, M. D., New York.
(Continued from page II4-)
Electrolysis. — When a galvanic current is concen-
trated within animal tissue by a close approximation of the
electrodes, or when, by means of the " polar method " and
insulated needles, a galvanic current of high intensity is
made to traverse some selected spot upon the human body,
there is apt to be a chemical decomposition of the water
and salts, and a coagulation of the albuminous elements of
the tissue thus acted upon. The salts are then separated
into their bases and acids, while the water is simultaneously
decomposed into hydrogen and oxygen. The positive pole
attracts to it the acids and the oxygen ; the negative pole
attracts to it the alkalies and the hydrogen. For this reason
the insulated needles tend to become oxidized when they
are connected with the positive rheophore. They do not
become so when attached to the negative rheophore. The
free alkalies deposited at the negative electrode are apt,
on the other hand, to cause destructive effects upon adja-
cent tissues. These are greatly in excess of that produced
by the oxidation of the metal points of the insulated needles
when joined to the positive rheophore.
When we wish to test the strength of the current which
we propose to employ for electrolysis, it may be easily done
by sending the current through the white of an egg for
twenty or thirty minutes. In that time it should coagulate
the albumin.
In order to reach the parts upon which we most desire
to perform electrolysis, it is often necessary to perforate the
skin and the muscles. To do this, needles are employed.
They should be insulated with hard rubber, collodion, or
shellac, except at their point for one half-inch, and the un-
covered part should be gilded, as a rule, in order to prevent
its oxidation. They should be from two to five inches long ;
should be strong enough to penetrate tissues without a lia-
bility of breaking ; should be as small as is consistent with
the current-strength to be employed ; and should be so
arranged as to enable the operator to adjust them in a
handle to which one of the rheophores of the battery may
be attached. Ordinary sewing-needles strung on a wire
may be employed in treating superficial nsevi, tumors, etc.,
if you lack the instruments specially designed for the pur-
pose. You may shellac them for insulation if deemed best.
It is very important, in some cases, that the insulation
of the needles employed be as perfect as possible ; and that
the tips of the needles be triangular or lancet-shaped, in
order that they may penetrate the skin with ease. The
needles and handle required can be bought of any manufac-
turer of electrical appliances.
The battery employed for electrolysis need not be un-
like that for ordinary medical purposes. Twenty-four of
Grenet's cells will produce a sufficient intensity of current,
provided they are freshly filled. Robin's statement that a
current of forty-five milliamperes is requisite must be based
upon a very limited external resistance. It is well to use a
battery of greater power than is actually required, so that
fresh -cells can be added, without breaking the current dur-
ing the operation, when deemed necessary. Personally, I
prefer insulated copper wire for rheophores when perform-
ing electrolysis, in preference to the tinsel cords commonly
employed for electric applications. They are less flexible
than the tinsel cords, but they are vastly superior to them as
conductors.
Fig. 37. — Electrode for Electrolysis (with three insulated needles).
Electrolysis has been employed for the following pur-
poses, with more or less success :
1. The coagulation of blood in aneurysmal sacs.
2. The relief of naevi and erectile tumors.
3. The cure of cystic tumors.
4. The cure of goitre.
5. The cure of echinococci.
6. The cure of ovarian cysts, and those of the broad
ligament.
7. The cure of urethral stricture.
8. The cure of malignant and fibroid growths.
9. The cure of hydrocele.
10. The destruction of the fcetus in extra-uterine preg-
nancy.
11. The removal of cicatrices, polypi, and other new
formations.
Respecting the treatment of large aneurysmal sacs by
this method, statistics show that the operation merits more
general recognition, as a means of possible cure of intra-
thoracic and abdominal aneurysms which can not be safely
treated by ligation, than it has received. Nine cures out of
thirty-seven cases have been collected by Duncan from vari-
ous sources; and Bartholowhas since collected others which
have been benefited by it, although not positively cured.
In none of these cases, so far as I can ascertain, was the cur-
rent-strength measured by a galvanometer. There is reason
to hope that the operation may become more generally em-
ployed when the steps of the procedure necessary to its suc-
cess are determined with greater exactness. There seems
to be a doubt, as yet, regarding the best method both of
generating and directing the current, so as to prevent sup-
puration and secondary haemorrhage. In two cases of blood-
sacs upon the face, intrusted to my care, I have succeeded
in consolidating the tumor and effecting its radical cure by
this means without suppuration or other complications. I
employed the positive rheophore for the needles, and placed
the cathode at the nape of the neck in both cases. The
duration of the two sittings in each case was about ten
142
RANNEY: LECTURES ON ELECTRICITY IN MEDICINE.
[N. Y. Med. Joub.,
minutes, and twenty-four Grenet cells were employed. I be-
lieve that the anode produces the firmest clot ; hence tlie
danger of haemorrhage on the withdrawal of the needles is
less than when the cathode is employed. The risk of em-
bolism, as a result of disintegration of the clot, does not
seem to be so great as one might at first imagine.
(a) (6)
Pig. 38 — An Electrode for Electrolysis". The needles are fine and nu-
merous, and are arranged as shown in (b). This is an excellent device for
effecting the cure of diffused nsevi, small glandular tumors, etc.
The employment of electrolysis in cystic tumors of the
neck, the ovaries, and the thyroid gland, has been resorted
to by many experimenters of note. Among these may be
mentioned Althaus, Amussat, Ultzraann, Clemens, Seme-
leder, and others. Some of the cases reported seem to point
toward this method of treatment of these diseased conditions
as potent and comparatively devoid of danger if properly
carried out.
The treatment of urethral stricture by electrolysis I have
always heretofore combated — chiefly because I think it less
safe and far less certain than gradual dilatation. I must con-
fess, however, that I have had no personal experience in the
electrical treatment of stricture ; and that my prejudices
may be more or less without foundation. My perusal of
the reported cures by this method has not, as yet, carried to
my mind a conviction of my error. The method seems to
me to lack precision, which should, to my mind, form the
basis of all surgical procedures within that canal. I am
having made for me some modifications of urethral elec-
trodes which I believe will insure greater precision than
any yet devised ; and I propose to give them a thorough
trial.
Ordinary cases of goitre, and the enlargement of the
thyroid gland which accompanies Basedoui's disease, have
been cured by electrolysis. Rockwell and Butler have re-
ported some astonishing results in the treatment of exoph-
thalmic goitre by galvanism of the thyroid gland. Rock-
well places the cathode over that body and the anode over
the solar plexus, combined with the employment of the
anode in the auriculo-maxillary fossa and the cathode over
the cilio-spinal center (cervical segments of the spinal cord)
at each sitting. His cases of reported cure required from
fifty to sixty-nine sittings. Needles were occasionally em-
ployed upon the goitre. This treatment was supplemented
by the use of iron, zinc, digitalis, and ergot ; and a restricted
diet, with instructions regarding the necessity of the repres-
sion of the emotions and passions, was enforced.
The arrest of extra-uterine pregnancy by electrolysis, and
also by shocks transmitted through the sac from Leyden
jars charged with static electricity, constitutes, perhaps, one
of the most successful and remarkable contributions to medi-
cine. The former method has proved the most reliable.
Needles are inserted into the sac and a current is sent
through the foetus of sufficient intensity to destroy life.
The treatment of cancer by electrolysis has been followed
by satisfactory results in some cases, according to the ob-
servations of Beard, Butler, Mussey, and Neftel. The ques-
tion of accurate diagnosis of the cases reported as cured
must still be considered as unsettled. The results appar-
ently obtained should certainly awaken the profession to a
trial of this method of treatment of a malady which inter-
nal medication, caustics, and the knife seem powerless to
combat.
Bartholow reports a cure of four out of six cases of
fibroid tumors of the breast by electrolysis. The remaining
two patients failed to continue treatment for a sufficient
length of time. He did not employ needles in any of these
cases.
The relief of hydrocele by the introduction of two nee-
dles connected with the rheophores of a galvanic battery and
brought within a half-inch of each other at their points has
been reported by Rodolfi, Frank, Bartholow, and others.
Some of the cases reported as cured required only one
application.
In dismissing this subject it may be well to summarize
the effects of electrolysis, as follows:
1. A feeble current tends to cause dilatation of the
capillaries and the lymphatic vessels, and thus to aid in
absorption.
2. A stronger current decomposes the salts and the
water of tissues, and coagulates the albuminoid elements.
3. A disintegration of the tissues immediately adjacent
to the pole which produces the effects previously described
takes place, with an escape of bubbles of gas, when the de-
composition of tissues is active.
4. As an eschar may be formed by a current of great in-
tensity, it is maintained by some authors that the cicatrix
which results from such a slough is soft and pliable if the
eschar has been made by the anode, and dense, with a ten-
dency to contract, when due to cathodal action. I am un-
able to confirm or deny this statement.
5. The danger in electrolysis is that of "doing too
much " rather than too little. The former error can not be
repaired ; the latter can by repeated sittings.
6. When an escharotic effect is desired, it is well to
have the needles made of zinc. The decomposition of the
chloride salts forms indirectly the chloride of zinc, be-
cause the liberated chlorine attacks the needle. This is ab-
sorbed by the tissues adjacent to the needle, and an escha-
rotic effect is thus produced. In the treatment of malignant
growths such needles, with currents of weak intensity, and
long sittings, seem particularly well adapted. This method
is almost painless, and has produced excellent results in
some cases reported.
7. The introduction of needles into the tissues is not an
absolute necessity when treatment by electrolysis is indi-
cated. The same effects to a lesser degree may be obtained
by placing the electrodes in contact with cutaneous or mu-
cous surfaces.
8. The employment of iron needles has been suggested
for the rapid coagulation of blood, on account of the styp-
tic effect of the chloride of iron which tends to form by
the liberation of chlorine from the chlorides of sodium, po-
tassium, and calcium.
The Galvano-Cautery. — When a large quantity of elec-
August 8, 1885.]
RAN NET: LECTURES ON ELECTRICITY IN MEDICINE.
143
tricity is forced through the resistance offered to its passage
by a platinum wire or a strip of platinum (usually bent into
the form of a knife), the beat produced causes the platinum
to rapidly approach redness or whiteness. Such an arrange-
ment is known as a " cautery-loop " or a " cautery-knife."
The battery which is employed to generate electricity in
sufficient quantity to accomplish such a result is known as
a "cautery-battery." In cautery-batteries the plates are
large and near together ; hence unusual precautions have to
i be taken to prevent " polarization," which takes place very
rapidly on account of decomposition of the fluid in which
the elements are immersed.
Of all the devices which have been suggested to over-
come this difficulty, I prefer that of Dr. Piffard. In the
battery devised by him the zinc plates are perforated, so
that the fluid can be forced through them upon the plati-
num plates by means of a rocking motion when the battery
is in action. The assistant who operates the battery can
produce any degree of heat required by making the plates
move slowly or rapidly through the fluid. The key-board
of the battery is so connected by means of large thumb-
screws that the elements can be connected for either quan-
tity or intensity, as the operator may desire. The rheo-
phores are composed of large copper wire, heavily insulated
with rubber.
(6)
Fig. 39.— Piffard's Cadtert Battery, (a) The battery as suspended when
not in action. (6) Arrangement of the top of this battery, Bhowing the screws
which regulate the connections between the different cells. The battery is
rocked during its action to prevent extreme polarization. By making the
movement slow or rapid, the heat of the loop or knife may be regulated at
will.
I have made several improvements upon the original
Piffard battery of late, which, in my opinion, will increase
the ease of working the instrument. They are not, as yet
fully perfected.
It may be advisable to again impress upon you the fact
that batteries designed for ordinary medical purposes are
totally unfit for heating a cautery-loop or producing an
electric light. A battery designed for cautery purposes is
also totally unfit for other purposes in medicine.
In operations upon the tongue, nose, pharynx, uterus,
vagina, rectum, and in some other regions, the galvano-cau-
tery seems destined to supersede the scalpel and ecraseur.
No blood need be lost in amputations of considerable magni-
tude, provided the operation is skillfully performed. If the
loop is employed, it is slipped when cold over the part to
be removed. It can be adjusted, therefore, with every pre-
caution against accident. After the current is turned on,
the heat of the wire even can be regulated with great pre-
cision. Care should be exercised against drawing the wire
too closely to the handle, and in selecting a wire which will
not burn off or prove too large for the battery employed.
As in all surgical procedures, this instrument should be
handled by an expert. It is well for a novice to practice
upon pieces of meat or bone until he familiarizes himself
with the details of its use, in case he meditates performing
an operation upon a human subject. When operations are
to be performed within the mucous cavities of the body,
the patient has frequently to be trained to tolerate the ne-
cessary manipulation. A dull red heat is preferable to a
white heat in dividing vascular tissues, and it is very impor-
tant that the division be slowly performed. When the skin
is to be embraced within the loop, it is well to divide it first
with a cautery-knife, and subsequently to adjust the wire.
The cautery-knife has been successfully used in remov-
ing cancerous growths within mucous cavities, in tubal
pregnancy, in tracheotomy, in extirpation of the breast, and
many other similar procedures.
An attachment to the cautery-battery, known as the
" dome cautery," consists of a coil of platinum wire over a
cone of porcelain. These may be of any size, and the por-
celain cone may be omitted if deemed necessary. It may
be employed in destroying hypertropliied tonsils, haemor-
rhoids, polypi, nsevi, epithelioma, etc.
The great advantage which the galvano-cautery has over
the use of the knife is the absence of haemorrhage and of
great pain. The platinum knife can be made of any form
desired. There is no limit to special forms of attachments
which maybe devised to simplify its use indifferent regions
of the body.
In operating upon the tongue, needles may be passed
through the organ in front of the site selected for the loop,
so as to prevent slipping of the wire. Bryant, who has had
an extensive experience in this operation, recommends a
twisted wire rather than a large one. There is some reason
to believe that the heat tends, moreover, to destroy (in the
case of cancerous growths) the germs of the disease which
might elude the knife.
General Rules governing Electro-Therapeutics.
Before we pass to the consideration of. special methods
of employing electricity in the treatment of disease, it seems
144:
RANNEY : LECTURES ON ELECTRICITY IN MEDICINE.
[N. Y. Med. Jock.,
to me advisable to suggest a few rules which may possibly
aid you in deciding where and how to direct your treat-
ment in any special case. There are, of course, some excep-
tions to each of these rules ; but they are, nevertheless, suffi-
ciently accurate to be used as guides in your practice :
1. Soak your electrodes in a weak solution of table-salt,
not in simple water. This diminishes the resistance afford-
ed by the skin at least fifty per cent.
2. Always press your electrode firmly and evenly
against the part which it touches. This renders the cur-
rent employed an even one to the patient and assists in its
conduction.
3. Put a milliampere-meter or a galvanometer, as well
as the body of your patient, into circuit, and record all your
observations, respecting the current-strength employed, from
its scale. It is neither scientific nor accurate to simply re-
cord the number of cells employed. Cells grow weak by
long-continued use, by polarization, and other causes. In
case a faradaic instrument is employed, a galvanometer is
useless; hence you should record the number either of cen-
timetres or inches of the primary or secondary coil em-
ployed.
4. Always endeavor to apply one of the poles to the
part which is diseased. The plates which I show you indi-
cate the situation of the " motor points " of the head, trunk,
and extremities. Such plates will enable you to direct your
treatment to any special nerve or muscle.
5. Acquire, by frequent experimentation upon yourself,
a knowledge of the effects of different current-strengths, the
situation of most of the more important nerve-trunks, the
formulaB of contraction of healthy nerve aud muscle, and all
other information necessary to the use of electricity in
medicine.
6. Never use too strong a current upon a patient at the
first sitting. It may frighten him, and he may never re-
turn. It is always best to begin with weak currents ; in
the majority of cases weak currents are indicated rather
than strong ones.
7. If you have no galvanometer, the intensity of a gal-
vanic current can be approximately determined by the burn-
ing sensation produced in the skin by the electrodes when
they are applied to it.
8. The " polar method " is more painful when the fara-
daic current is employed than when the galvanic current is
used. It is not well to separate the poles of a faradaic ma-
chine too widely ; pain is intensified, and no special benefit
is gained by so doing. Remember that the faradaic cur-
rent has no fixed polarity. A galvanometer will record the
difference between the current produced by the "make"
and " break " of the circuit only ; hence it is of no value in
determining the intensity of the faradaic current actually
administered to a patient.
9. The " polar method " is absolutely requisite to elec-
tro-diagnosis when the galvanic reactions of nerve or mus-
cle are being tested. It constitutes the best method also of
administering the galvanic current for therapeutical pur-
poses, because it is usually important that the anode or
cathode exert its special influence upon the part diseased.
The farther apart you place the poles, the less is the effect
of the indifferent or neutral pole upon the part which you
wish chiefly to influence.
Although clinical experience seems to prove that we ob-
tain different results in the majority of cases by employing
the anode or cathode upon the part to be influenced, I am
inclined to question the correctness of the view that those
effects are in any way dependent upon the direction of the
transmitted current. We know that it is not possible to
transmit an electric current in any one direction by means
of animal tissues. Every current becomes diffused to a
greater or less extent, as is illustrated in diagrams prepared
by Erb and other authors upon electro-therapeutics. It is
probably more correct to view the special effects obtained
by employing the positive and negative poles of a galvanic
battery as the effects of the poles themselves, rather than
the result of the direction of the current.
10. Remember that the anode or positive pole of a gal-
vanic battery is the sedative pole, and the cathode or nega-
tive pole is the stimulating or irritating pole. When the
cathode is made the indifferent pole, it is well to use a very
large electrode.
11. Do not change the polarity of a current during its
application to a patient any oftener than circumstances de-
mand. As a rule, it is unnecessary to do so at all. It
causes unnecessary irritation, which should always be avoid-
ed. In the treatment of neuralgia, diseased conditions of
the brain or spinal cord, and painful points, it should never
be done without some special reason. It is positively con-
tra-indicated when catalytic effects are desired.
12. When galvanic currents to the head are indicated
(especially if the current is to be sent through the brain),
employ only those of moderate intensity (save in excep-
tional cases), and do not reverse the current unless there is
good reason for so doing. When you read about thirty-
cell currents being sent through the brain, it is safe to sup-
pose that the battery was not of the most active kind, or
that the ability of the patient to endure such a current was
very exceptional. It is rare to meet with a patient who can
tolerate a current of more than from three to six milliam-
peres through the brain, and it is not safe to break currents
of high intensity when employed about the head.
13. Static electricity will sometimes produce muscular
contractions when faradaic currents will not. In hysterical
conditions, some of the spasmodic diseases, sciatica, and
organic spinal affections, it is well to try this form of elec-
tricity when galvanism fails to afford relief.
14. Respecting the duration of individual applications
of electricity in its various forms, my experience teaches
me that short sittings accomplish as much, and often more,
than long ones. I seldom exceed five or six minutes, unless
I am endeavoring to induce catalytic action, to benefit
chronic articular rheumatism, etc. ; or when I am employ-
ing general faradization, general galvanization, central gal-
vanization, electrolysis, the galvano-cautery, or other pro-
cedures which require a longer sitting. Frequently, thirty
seconds to two minutes is all that is required when some
particular part of the body is alone to be galvanized or fara-
dized.
15. It is impossible to lay down any rule which will
August 8, 1885.]
CTDWYER:
INTUBATION OF THE LARYNX.
145
guide you in determining the frequency of the applications
required by any individual case. It is seldom necessary to
employ this agent oftener than every day, and three sittings
a week will suffice in the majority of cases. If the dis-
ease is of a chronic type, it is often advisable to occasion-
ally discontinue treatment for a few weeks, and then to re-
new it with vigor. Experience has taught me that the
effects of electricity are more vigorous after such intermis-
sions. It is often well to change from galvanic to faradaic,
and again to static, currents, from time to time, in the treat-
ment of obstinate diseases which fail to progress satisfac-
torily.
16. I would advise you to be persistent in employing
this agent when your judgment tells you that it is advisable
to begin it. Many of the chronic forms of cerebral and
spinal diseases are materially benefited and often completely
cured by a proper course of electrical treatment which has
been followed, with occasional intermissions, for some
months during each year for several years.
17. As adjuncts to a course of electrical treatment, you
will find massage, baths of various kinds, a change of cli-
mate, enforced rest in bed, and judicious internal medi-
cation, indicated in special cases. Delicate subjects, who
suffer from neurasthenia, hysteria, persistent neuralgias,
mental depression, sleeplessness, morbid fears, excessive
" nervousness," rapid or extreme emaciation, profuse and
persistent sweating of the palms or feet, dyspeptic symp-
toms, and the thousand other manifestations of debility,
are especially benefited by these adjuncts to a judicious use
of electricity.
18. When simple excitation of motor or sensory nerves
is demanded, the faradaic or static current is the best one
to employ.
19. As a counter-irritant, and in the treatment of anajs-
thesia, dry faradization with a wire brush excels all other
electrical applications, unless it be the use of static elec-
tricity.
20. In spasmodic diseases, in neuralgia, and other like
conditions, galvanism and static electricity are alone of ma-
terial service.
21. Interrupted galvanic currents are of service when
muscular contractions of a forcible character are desired.
When degeneration of a nerve exists, these can not be pro-
duced by the faradaic current.
22. The size of the electrodes modifies the density of
the current directly. When large, the current is less dense
because it is more diffused. The cathode should, as a rule,
be larger than the anode when electrical applications are be-
ing made.
(Original Communications.
INTUBATION OF THE LARYNX.
By JOSEPH O'DWYER, M. D.
It was not my intention to publish anything in relation
to my method of tubing the larynx in croup and kindred
diseases until I had brought my instruments to a greater
degree of perfection than I can claim for them at present,
but, as several references to this subject have appeared in
the journals and reports before medical societies, I have
concluded to give the profession a brief account of the
progress I have made, with a description of the instruments
and the method of using them.
At the time I began my experiments, almost five years
ago, and for more than a year subsequently, I was unaware
of Bouchut's similar attempt and failure in 1858. His
abandonment of any further experiments after such a lim-
ited trial as seven cases of croup, treated with very imper-
fect instruments, must be attributed solely to Trousseau's
unqualified condemnation, in his report on this subject to
the Paris Academy of Medicine, soon after the publication
of Bouchut's cases. Trousseau was at that time strongly
advocating the operation of tracheotomy, and, from the
brief reports on this subject that I have read, it does not
appear that he ever tried tubage of the glottis himself or
witnessed its trial by others, but condemned it on purely
theoretical grounds.
Bouchut in his experiments used a short cylindrical
tube, introduced into the larynx on the end of a hollow
sound, to which a thread was left attached and brought out
through the mouth, for the purpose of removal. It is re-
ported as having produced an extreme amount of irritation,
in some cases necessitating its prompt withdrawal, but, not-
withstanding the great lack of conformity between the
shape of the tube and that of the rima glottidis, I am con-
vinced from my own experiments that the greater part of
this irritation was produced by the constant contact of the
silken thread with the epiglottis and base of the tongue.
Even in my earliest experiments, and with the imperfect
tubes I was then using, I did not encounter any such marked
irritation, but, on the contrary, was surprised at the toler-
ance displayed by the larynx for this kind of foreign body.
In attempting to construct a tube for the larynx, the
first serious difficulty encountered was how to make it self-
retaining. I could think of nothing more likely to accom-
plish this result than having it arranged in the form of a
bivalve, similar to the bivalve speculum but elliptical in
shape, with a narrow transverse diameter and having a shoul-
der to prevent its slipping into the trachea. This cannula
was so constructed that, while being introduced, the blades
were approximated and opened as soon as detached from
the introducing instrument.
I will not enter into any details concerning my numer-
ous experiments with various modifications of this instru-
ment, except to state that it was always retained and gave
prompt but transient relief to the dyspnoea, a return of
which was due to intrusion of the swollen mucous mem-
brane between the blades in the infraglottic division of the
larynx.
My next trial was made with plain tubes, also elliptical
in shape and about one inch long. The reason for having
them so short was the belief that longer ones would be dif-
ficult to introduce. My first experience with these was in
an infant aged two months and twenty-four days, in the
suffocative stage of diphtheritic croup. Immediate relief
to the dyspnoea, which was extreme, and a refreshing sleep,
146
CLWYER : INTUBATION OF THE LARYNX.
[N. Y. Med. Jocb.,
followed the introduction of the tube. During the succeed-
ing seventeen hours that it lived, most of which time was
passed in sleep, almost a pint of milk was taker through a
nursing-bottle. Death took place without any appearance
of suffering.
The second case was that of a little girl aged three years
and a half, in the service of Dr. J. Lewis Smith at the New
York Foundling Asylum, suffering from the most urgent
dyspnoea due to the same cause. In the presence of Dr.
Smith and Dr. Blodget I introduced a tube with prompt and
permanent relief. I removed it on the fourth day, but was
obliged to reinsert it at the end of five hours, owing to are-
turn of the obstruction. During an attack of coughing it
was expelled on the seventh day, and, although the cough
continued croupy for several days, with considerable dysp-
noea at times, it was not found necessary to insert the tube
again. She made a rapid recovery, with complete restora-
tion of the voice. For the seven days this little patient
retained the tube in her larynx she not only made known
her wants in a very audible whisper, but kept up an almost
continuous chatter with her attendants, the best possible
proof that the irritation produced was not great. She swal-
lowed fluids, such as milk, with considerable difficulty, usu-
ally coughing after each deglutition, but solids and semi-
solids with comparative ease.
From the foregoing cases I was led to hope that these
tubes would prove self-retaining without further modification,
but in the next case, that of a boy aged four years, a tube of
suitable size was expelled almost immediately ; a larger fol-
lowed the same course ; the largest size I had, which was
much too large for this age, was finally retained. Dyspnoea
returned within twenty -four hours, and death took place
with apparently as much suffering as if no tube had been
used.
At the autopsy, the lower end of the cannula, which ex-
tended only into the narrow upper portion of the trachea
where the latter unites with the infraglottic division of the
larynx, was found obstructed by a thick deposit of pseudo-
membrane, considerable of which also existed in the
bronchi.
This case proved the necessity for longer tubes, and I
procured a set, the largest of which was one inch and a half
long, and the smaller somewhat shorter. As these were not
retained any better than the former, and I was convinced that
still longer ones could be introduced, I ordered a set the small-
est of which was one inch and three quarters, and the largest
three inches in length. They were constructed in accord-
ance with a large number of measurements of the trachea
at different ages, and would reach within half an inch or
less of the bifurcation, thus overcoming obstruction in
the trachea as well as the larynx. I also entertained the
hope that the increased length would prove an important
factor in preventing their expulsion, but had serious doubts
about the possibility of introducing them. By having the
curve on the introducing instrument very short, I experi-
enced no more difficulty in passing these into the larynx
than the much shorter ones previously used. In some cases
they were retained, but in the majority were promptly
coughed out.
The next attempt at overcoming this difficulty was the
addition of a wedge-shaped piece of metal to the lateral
aspect of the same tubes, half an inch from the upper ex-
tremity, with the thick end looking upward, which was in-
tended to hold beneath the vocal cords. This accomplished
the desired result, but at the same time retained them so
firmly that their removal was rendered very difficult, and, as
this would prove an insuperable objection, it was abandoned
after a brief trial.
The tubes I am using at the present time differ in every
respect, except length and caliber, from any heretofore tried.
In order to give greater freedom of action to the epiglottis
in protecting the aperture of the tube during the act of
swallowing, I have given the upper extremities of these a
slight posterior curve, with some degree of obliquity from
before backward and upward, and, from my limited experi-
ence with them, deglutition is certainly less difficult than
with the straight ones formerly used. But, as the epiglottis
is only an accessory to the closure of the larynx, and the
other more important factor, the action of its constrictor
muscles, is prevented by the presence of the cannula, it is
evident that the deglutition of fluids can never be perfect
with any form of tube in the glottis.
The device adopted for preventing their expulsion con-
sists in increasing the narrow transverse diameter about the
center, without changing the caliber, so as to make the tube
at this point almost cylindrical, and gradually inclining up-
ward and downward somewhat in the shape of a double
wedge. In the few cases in which I have used this modifi-
cation it has proved self-retaining, and, should it continue to
do so on a more extended trial, I believe there will be very
little scope for further improvement, except, possibly, to in-
crease the length so that it will reach still closer to the
bifurcation, which would be of doubtful utility, as, after a
very considerable experience in the dead-house, I have never
yet found an exudation thick enough to produce obstruc-
tion in the lowest and widest portion of the trachea without
at the same time having extensively invaded the bronchial
tubes.
As all my work, up to a very recent period, has been of
a purely experimental character, and as I am not prepared
even now to say that further modification of these tubes
may not be necessary in order to make them absolutely self-
retaining, without which they would not be available for
general use, I will leave all considerations as to the value of
this method of treating croup and other acute stenoses of
the larynx to be determined by a more extended trial in the
future. At the same time I will venture the prediction that
in the near future it will be recognized by the profession as
a legitimate and valuable method of overcoming obstruc-
tions in the upper air-passages with a rapidity by no other
means obtainable.
I believe these tubes will also prove valuable as dilators
in chronic stenoses of the larynx or trachea, and particularly
in those cases following tracheotomy where it is found im-
possible to dispense with the tube. Not having had any
experience with such, I can give no facts as to the length of
time a tube can be worn without injury ; but some valuable
inferences may be drawn from the time it has been retained
August 8, 1885.] GLASGOW: VASO-MOTOR DISTURBANCES OF THE NASAL MEMBRANE.
U7
in acute stenosis. For instance, in two of my cases of diph-
theritic croup that ended in recovery, the cannula was worn
in each for the space of ten days without the slightest im-
pairment of the vocal apparatus, and from this it is reason-
able to infer that it would be tolerated in the healthy larynx
for a much longer period, and probably, if worn intermit-
tinglv, for an indefinite period.
The following is the method of introducing the tube,
which is done without the use of an anaesthetic : The child
is held upright in the arms of a nurse and the gag inserted
in the left angle of the mouth, well back between the teeth,
and opened widely ; an assistant holds the head, thrown
somewhat backward, while the operator inserts the index-
finger of the left hand to elevate the epiglottis and direct
the tube into the larynx. The handle of the introducing
instrument is held close to the patient's chest in the begin-
ning of the operation, and rapidly elevated as the cannula
approaches the glottis. As soon as the obturator is removed,
and it is ascertained with certainty that the tube is in the
larynx, the thread which is attached for the purpose of re-
moval, should it be found to have passed into the oesopha-
gus, is withdrawn, but at the same time the finger is kept in
contact with the tube to prevent its being also withdrawn.
Its removal is accomplished in a similar manner ; but, as
it is difficult, on account of the struggling of the child, to
guide the extracting instrument into the narrow aperture of
the tube, I prefer to give an anaesthetic for this purpose.
Fig. 1 gives an anterior view of the tube ; Fig. 2, a
lateral view of the same attached to the introducing instru-
ment; Fig. 3 shows the extracting instrument; Fig. 4, the
mouth gag.
Dr. J. Lewis Smith, in an article on croup, in the April
number of the " American Journal of the Medical Sciences,"
speaks of tubage of the glottis in a manner that would lead
his readers to infer that it was a well-recognized operation
with which the profession was quite familiar. The only
previous attempt ever made to tube the larynx (excluding
the use of catheters and long tubes of every kind) with
which I am acquainted was Bouchut's, previously referred
to, the only result of which was to deter others from trying
similar experiments. Dr. Smith's familiarity with this sub-
ject, no doubt, arose from our association at the New York
Foundling Asylum, where my experiments were almost ex-
clusively conducted.
There are several important points in connection with
this subject the consideration of which I shall have to defer
to some future time.
The manufacturer of these instruments is H. Keller, of
106 West Thirty-seventh Street.
ON CERTAIN
VASO-MOTOE DISTURBANCES
OF THE NASAL MEMBRANE*
By WILLIAM C. GLASGOW, M. D.,
ST. LOUIS.
For a number of years my attention has been attracted
by a series of cases which could not be explained by the
well-known factors of inflammatory process. Resembling
them in some particulars, still there are differences which
necessitate an additional and independent influence for their
production. The laws of vaso-motor action, although still
imperfectly developed, would seem to explain them, and
the success attending the use of therapeutic agents would
seem to verify it. During the last few years the subject of
vaso-motor disturbances of the nasal membrane has been
very fully developed by several members of this society, and
especially by Dr. Mackenzie, of Baltimore, Dr. Roe and Dr.
Daly, and our co-laborer, Hack, of Freyburg. I find, how-
ever, that my experience of these cases has been somewhat
different from that of my confreres, and I would aim in this
paper to record my views and the conclusions which they
would seem to justify. For a number of years my atten-
tion has been attracted by a series of cases characterized by
great swelling, more especially of the cavernous tissue, a
profuse discharge of limpid fluid, and abnormal paleness
of the mucous membrane. Formerly, when they occurred
dining the summer months, I was content to consider them
as modified types of so-called hay fever. When, however, I
found they occurred during the year irrespective of seasons,
I became convinced that there was a different agency from
that then recognized as an essential factor in hay fever, i. e.,
the pollen of Wyman, Blakley, and Phoebus. Dr. Beard's
work first attracted my attention to the possibility of a neu-
* Read before the American Laryngological Association, June 24,
1885.
148 GLASGOW: VASO-MOTOR DISTURBANCES OF THE NASAL MEMBRANE. [N. Y. Med. Jock.,
rosis being the chief factor in the disturbance, and gave me
my first ideas of what I considered to be the true theory of
these cases. Considering the so-called hay fever to be a
functional disorder of the nervous system, in which the
over-sensitiveness of the nasal mucous membrane occurs, and
producing through this certain well-known reflex symptoms
and disturbances of the normal vaso-motor action, I can still
consider these cases as closely allied, both in aetiology and
mechanism, with the so-called cases of hay fever. From a
number of cases I have selected three, showing the distinct
and different types of nasal disturbance. I would eliminate
from consideration another class of cases in which we find
neuralgia, especially orbital, supra-orbital, and frontal, oc-
curring as a result of subacute rhinitis ; although having
manv of the pathological conditions found in Case II, still
there is wanting the primary neurotic element capable of
producing the vaso-motor disturbance.
Case T. — I. W., an Englishman, a merchant, forty-five years
of age, was brought to me for consultation by his physician.
He was of stout build, somewhat florid, and had been generally
healthy. He was suffering acutely with a neuralgia of the supe-
rior maxillary nerve of the left side, and complained of great
obstruction, with a profuse flow of a clear watery fluid from the
left nostril. He stated that this had only commenced with the
neuralgia, and had been constant. On examination, the left nos-
tril was found occluded by a swelling of the cavernous tissue;
the mucous membrane was colorless in appearance, and seemed
to be saturated with moisture which constantly oozed from its
surface. The touch of the probe produced instantly an increase
of the swelling and an increase of the discharge of the limpid
fluid. The right nostril was normal and unobstructed. He was
treated by his physician for the neuralgia, and received no local
treatment. With the subsidence of the neuralgia the nasal dis-
turbance disappeared.
Case II. — Mrs. P., thirty-two years of age, well developed,
healthy, of a nervous temperament, and inclined to hysterical
attacks. Has had three children ; married eight years. Three
years ago she noticed a nasal trouble for the first time, although
for many years she had been suffering with follicular pharyngo-
laryngitis and naso-pharyngitis. Her first attack occurred dur-
ing pregnancy, and has been repeated at irregular intervals
about four times a year. There is no special dependence upon
atmospheric conditions. The attacks usually occur at the be-
ginning or at the close of the menstrual epoch. The first symp-
tom is a violent sneezing, occurring in paroxysms, with a pro-
fuse watery discharge from the right nostril. This is soon fol-
lowed by an intensely painful spot in the right nostril, and by
neuralgic pains radiating to the eye and the frontal regions.
Congestion of the conjunctiva, lachrymation, and ptosis of the
right lid soon follow. The right nostril becomes completely
closed, especially toward evening, and there is generally accen-
tuation of all the symptoms. The attack is accompanied by
slight fever, with general lassitude and loss of appetite. There
is also increase of the general arterial tension, as shown by the
pulse, and pronounced accentuation of the second sounds of
the heart. About the third day a plug begins to form in the
nostril, which completely prevents the passage of air. The plug
is of a dense structure. It is elastic and solid, and resembles
no other nasal secretion that I have seen. It resembles some-
what a piece of rubber, and the elasticity is well marked on
tearing it. The nostrils are now completely occluded by the
swollen membrane and the plug, and the probe can only be
passed by force. With the removal of the plug relief is given.
The walls become less swollen and the nostril opens. During
the next twelve hours another plug forms, and we find a renewal
of the same symptoms, only in a moderated form. Without
treatment this condition lasts ten days, with paroxysms varying
in intensity and gradually diminishing toward the end. The
nostril is then found in the normal condition, which is that of
hypertrophic rhinitis. During the attack the mucous mem-
brane is swollen and cedematous, pouring out quantities of lim-
pid fluid. It is of a pale red, the pallor being in marked con-
trast to the color of the other nostril. It shows complete
occlusion of the nostril, and it is exquisitely sensitive. The
slightest contact of the probe causes increased swelling and
profuse discharge, with violent paroxysms of sneezing; intense
pain is felt radiating from the nose to the orbital and supra-
orbital region, and immediate congestion of the conjunctiva is
produced. Relief of this condition is most marked by bleeding
the opposite nostril. The slightest touch of the knife produces
a free haemorrhage. The touch of the knife to the affected
membrane increases the symptoms, and little blood is obtained
unless the puncture is deep into the cavernous body. The
blood is always pale and watery. The bleeding is then followed
by the use of the hot alkaline sprays. By these means the
swelling is reduced and the plug can then be blown out. I have
also found the insufflation of the vapor of ether to have a very
happy effect in promptly reducing the swelling and drying up
the mucous membrane ; the nitrite of amyl has also produced
good effects.
Case III. — Miss S., thirty years of age, healthy, in excellent
general condition. Has periodical attacks in the spring and
fall of what she calls acute catarrh. When I saw her in March
she complained of great obstruction of the nostril, and profuse
watery discharge of both nostrils. On examination, both nos-
trils were found to be occluded by swelling of the cavernous
bodies, the mucous membrane cedematous, of a pale color. A
watery secretion seemed to be oozing from the mucous mem-
brane and the discharge was profuse. The touch of the probe
increased the swelling and the discharge, but produced no pain.
A deep puncture in the cavernous body produced a slight haem-
orrhage, the blood being very pale and watery. This always
opens the nostril. Insufflation of the vapor of ether gave a cer-
tain amount of relief. The instillation of atropine into the
nostril was also beneficial, as well as inhalations of camphor.
These attacks would last about two weeks, and were always
shortened by treatment, and the nostril would be left in a nor-
mal condition. In this case I found great benefit in the exter-
nal use, in the shape of liniments, of the camphor chloral, aco-
nite, and veratrine. This liniment was applied to the course of
the fifth nerve and over the nose.
These three cases, although resembling each other in
some respects, will be seen to be essentially different. In
Case I we see the effect on the mucous membrane, the irri-
tation being applied to the body of the nerve. In Case II
we notice the effect produced by the irritant being within
the nasal cavity in a case complicated by inflammation of
the membrane. We find added to the original symptoms
extreme sensitiveness and the tender spot with acute pain.
The presence of the plug causes a swelling of the cavernous
bodies, the swelling only subsiding on its removal. Case III
is to me obscure. I have seen several such cases, some of
them absolutely resisting all treatment for the reduction of
the swelling. It may be due to some derangement of the
vaso-motor centers, or some irritation within the nasal caual
which has been overlooked. In the three cases, and in all of
August 8, 1885.] OLASOOW: VASO-MOTOR DISTURBANCES OF THE NASAL MEMBRANE.
149
this character which I have seen, there are found the three
factors of great swelling of the cavernous bodies, abnormal
paleness of the mucous membrane, and profuse discharge of
the limpid fluid. And in all these cases these symptoms are
aggravated by the application of an irritant to the affected
membrane. These conditions I will consider to be due to
disturbed nerve action, probably altered tone in the minute
arterioles, produced by derangement of vaso-motor control.
The mechanism which causes the swollen and cedematous
tissue, the pale color of the membrane, and the profuse dis-
charge must be explained simply on theoretical grounds ;
and, in the present state of our knowledge of vaso-motor
action, it must certainly still remain problematical. Are the
cavernous bodies congested, as has been asserted ? Conges-
tion presupposes a dilatation of the blood-vessels, with in-
creased supply of normal blood. Under such conditions we
shall find, not pallor, but increased redness. The prominent
feature, however, in these cases is pronounced paleness, and
this, in my opinion, disproves the possibility of dilatation
of the blood-vessels. I would rather assume the opposite
condition to exist — a contraction of the arterioles, due to an
increased tone of the vessels caused by an augmented action
of the vaso-constrictors. In short, the minute vessels sup-
plying the arteries are in a state of spasm through nerve
irritation, the general arterial tension is increased, the on-
ward flow of the more solid portions of the blood is pre-
vented, and the cavernous bodies of the mucous membrane
become infiltrated with escaping white corpuscles and the
liquor sanguinis. To these must be added the liquefaction
and the increase of the glandular secretion, as the result of
gland stimulation. The theory of spasm of the arterioles is
supported by the favorable action of remedies which favor
arterial dilatation — such as atropine and nitrite of amy].
In the present state of the knowledge of the laws of vaso-
motor control it certainly is hazardous to base a theory on
such laws. But the conditions existing in the nasal cavity-
seem to me to be explained solely by this means. I firmly
believe that, whenever the laws governing the vaso-motor
system shall be more thoroughly developed, we shall find
more of the functional disturbances of the body to be due
to disturbed vaso-motor action than is generally believed.
DISCUSSION.
Dr. Roe. — The subject of neurosis of the nasal membrane is
certainly a very extensive one, and there are so many different
factors which enter into the consideration of the subject, that
many times the cause and effect are not properly differentiated.
In many cases the nose is the objective cause, and in many
cases, no doubt, the subjective cause. There is no reason why
the nose may not be affected in a subjective manner, from irri-
tations in other parts of the body, reflected through the sym-
pathetic system, as well as the larynx or other portions of the
body. But in the great majority of cases we find the nose to
be the primary seat of the reflex irritations. As an illustration
of this I will cite a case in point. Last summer, about a year
ago, a gentleman came to me with a moderate naso-pharyngeal
catarrh. In addition to his throat trouble he had marked pain
in his chest, which caused him great anxiety. He suspected
that he had a pulmonary difficulty. Careful examination of his
chest revealed no trouble whatever. But in his nose there was,
in addition to inflammatory trouble, an exostosis of the inferior
turbinated bone, which came in contact with the septum. I
advised him to have that removed, as the pain might be a re-
flected one, and as we are often surprised by the great amount
of trouble which is reflected from the nose, and also as neces-
sary in the cure of the nasal affection. He consented to the
removal, after which, within an hour or two, the pain in his
chest disappeared.
Dr. Robertson. — I have noticed in a large number of cases,
in subjects of hay fever, this peculiar paleness of the mucous
membrane. I think the case just related would naturally come
under that subject — i. e., that peculiar condition of the mucous
membrane which is due to an irritation of the nervous system.
I have such a case in mind who, I consider, had chronic hay
fever. She would have paroxysms of sneezing and discharge of
watery fluid from the nose. The peculiar paleness of the mu-
cous membrane and the usual hyperajsthesia of the membrane
were very marked. The attacks were frequent. They came on
during the summer, fall, or winter, but were undoubtedly of
nervous origin, because, with any mental disturbance, from
going to a party, or to school, she would sneeze twenty or thirty
times, and then the watery discharges would take place. This
case was treated with spray and with a preparation of eucalyp-
tol, with relief for a few days. I have noticed a number of
cases of hay fever in which this condition of the pallidity of
the mucous membrane and these peculiar watery secretions
were very marked. As far as swelling of the membrane is con-
cerned, it frequently occurs during the early stages of the dis-
ease, but gradually subsides. I believe it due to a swelling of
the cavernous portions of the turbinated bodies, with contrac-
tion of the membrane itself. There might be contraction of the
arterioles and capillary blood-vessels of the skin, and still directly
underneath the skin, congestion. In the turbinated bodies this
would only occur in conditions of disturbance of the vaso-
motor system.
Dr. Mackenzie. — I do not propose to reiterate on this occa-
sion all that I have said and written on the subject of which
Dr. Glasgow treats; but there is one point in regard to the
pallor of the mucous membrane, which is a good one, to which
my attention has not been directed before. On the contrary, I
have found in my experience that the opposite condition is the
most prevalent one. I think with the cases which Dr. Glasgow
has described you will allow me to include a number of so-
called hay fever, and of these some to which I have ventured
to give the name of sympathetic rhinitis. In its pathology two
factors enter. The peculiar irritability of the tissue of the nose
may be due to different causes: either from some local patho-
logical process, or from a host of other peripheral influences, or
from some irritation starting in the nervous centers, or possibly
due to some disease of the nervous system as a whole, or from
some reflex irritation from its various parts, or, finally, from
some disease of a distant organ. In one of my papers on vaso-
motor coryza I have called attention to the purely psychical
element in the production of the paroxysms. Lately I saw a
lady who had been suffering for over fifteen years with certain
forms of so-called hay fever. The paroxysms were so violent
that she was compelled to take to her bed and remain there in
great suffering until it was over. It was unquestionably a case
of so-called rose cold. She could not go into a room where
roses were without bringing on an attack. She was nervous
in the ordinary acceptation of that term, but was not, however,
hysterical. I had a perfect artificial rose constructed, of such
exquisite workmanship that it was the exact counterpart of the
original. I carefully kept this in a clean place in my office be-
hind a screen, and when she was expected I carefully removed
every particle of dust from it by a thorough washing. Several
days before I had used the galvano-cautery, and when she came
150
BULL: UNILATERAL TEMPORAL HEMIANOPSIA.
[N. Y. Med. Jour.,
to my office that morning she said she had never suffered so
little during the past fifteen years as during the three days
prior to conling to my office. After she had heen in my office
over a quarter of an hour I produced the artificial rose, and,
sitting dow n in front of her, dangled it in my hand, at the same
time conversing on some topic foreign to her case. In less than
a minute she said she would sneeze. In less than two minutes
she had intense itching at the nose, and in less than four min-
utes from the time I produced the rose from hehind the screen
the symptoms of asthma had commenced. As soon as the diffi-
culty in breathing had commenced, I removed the rose and told
her it was an artificial rose, and her astonishment was of course
very great. Four days afterward she came to my office. I
produced the most perfect specimen of a real rose, into the
center of which I plunged her nose and kept it there a long
time. I tried to get all the pollen I could in her nasal cham-
bers, and I think I was fairly successful. I kept it there for
about five minutes without exciting the slightest tendency to
the so-called rose cold. On the day on which I performed the
experiment with the artificial rose she entered my office appar-
ently a well woman, and left it with one of the severest coryzas
she ever had. The pallor of the raucous membrane is a point of
extreme interest, and worthy of our future consideration.
Dr. Harrison Allen. — I saw a case last winter which illus-
trated the point taken by Dr. Glasgow. A lady, the subject of
Bright's disease, suffered from intense irritation of the nasal
chambers, accompanied with absolute occlusion. The condition
was undoubtedly due to a constitutional cause, and yielded to
general remedies.
Dr. Rice. — I have been pleased with Dr. Glasgow's classifi-
cation of these cases, for there certainly is great difference in
the pathological appearances presented. In some we find all
the color of inflammation, and in others the pallor which has
been mentioned. In hay fever the inflammatory condition en-
ters more largely than in these so-called " neurotic cases " which
Dr. Glasgow has spoken of, the redness and swelling in one case
being due to dilatation of the arterioles, while the white, boggy
enlargement is caused by the transudation of serum, the capil-
laries being contracted. 1 have noticed the different action of
cocaine upon these two classes, and it may be made a means of
differential diagnosis. In simple inflammatory hypertrophies
of the nose we know that the swelling is instantly and com-
pletely reduced when cocaine is applied ; but in the white swell-
ings little effect is produced in causing absorption of serum.
Dr. Glasgow. — I think the point that the irritation of the
cavernous tissue is the primary one is not valid. The swelling
is simply the effect, and due to irritation. In the first case I
reported we had a beautiful illustration of disturbance without
an inflammatory condition. There was profound pallor, such
as I have never seen, except in the cadaver. Now, here irrita-
tion was increased, and the swelling of the cavernous tissue
was simply the effect of this disturbed nerve action. In the
second case there was a swelling of the cavernous tissue, due to
this same cause. Call it vaso-motor or not, it is a disturbed ac-
tion due to irritation in the nostril. Remove the plug, and you
immediately remove the swelling; so that the swelling could
not have been primary, but a secondary effect of the primary
nerve irritation. Dr. Mackenzie also beautifully illustrates this
fact in his rose experiment. I am a profound believer in this
mental influence; but I neglected to mention in my case that
the lady could intensify her colds by thinking about them.
If she had any little annoyance during the day, toward even-
ing her trouble would be greatly intensified.
The University of Vermont. — Dr. L. M. Bingham, of Burlington, has
been appointed Professor of Surgery, succeeding the late Dr. J. L. Little.
TWO CASES OF UNILATERAL TEMPORAL
HEMIANOPSIA*
By CHARLES STEDMAN BULL, M. D.,
LECTURER ON OPHTHALMOLOGY IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE:
SURGEON TO THE NEW YORK EYE AND EAR INFIRMARY.
Case I. — Unilateral Temporal Hemianopnia, with Central
Scotoma of the Other Eye. — Colonel A. D. N., aged sixty-six, a
retired officer of the army, was first seen by me on June 28,
1884, and told the following history: In the summer of 1849,
while at one of the Government posts on our western frontier,
he was struck by lightning as he was standing at the door of
his tent. lie fell to the ground and remained unconscious for
several hours. When he regained his senses, he discovered that
he was blind in both eyes; but this condition rapidly improved,
so that at the end of a few days he had regained his sight, and
in a short space of time had the perfect possession of all his fac-
ulties. He remained perfectly well in every respect till 1857,
nearly eight years later, when the muscles of the left thigh and
leg began to atrophy, and almost simultaneously there appeared
a sudden temporal hemianopsia of the right eve. The paresis
and atrophy of the muscles of the left lower extremity slowly
but steadily progressed till 1859, since which time there has
been no change. There has been no change in the field or power
of vision in the right eye since the hemianopsia first appeared.
He walks with comparative ease, but the muscles of the left leg
are markedly smaller than those of the opposite side, and he
tires easily on walking. About six months before I saw him he
noticed a central obscuration of vision of the left eye, which
came on suddenly, and this scotoma has existed ever since, and
he thinks has grown larger. He has never had rheumatism or
syphilis, has no hypertrophy or valvular disease of the heart,
and repeated and very careful examination of the urine has not
been able to determine any signs of chronic degenerative ne-
phritis. He has had intermittent fever of the congestive type
several times severely, and during the past six months he has
had several attacks of fainting, which have occurred without
any warning. He has never been addicted to drinking, aud for
many years has not touched alcohol, but he has all his life
chewed and smoked tobacco to excess. He was a man of fine
physique, with snow-white hair, but with a rather feeble, cau-
tions gait. On testing the vision, it was found in the right eye
= ^| + , with no vision on the temporal side of the median ver-
tical plane of the eye. In the L. E., V = T§T eccentrically. A
very careful examination of the field of vision was then made,
and repeated at each subsequent visit, but all the examinations
gave the same result. In the R, E. there was entire loss of the
temporal half of the field. In the L. E. there was concentric
narrowing of the field and also a central scotoma, which was of
an irregular oval in shape, with the long diameter of about 30°
vertical, and the short diameter 20° horizontal. An ophthalmo-
scopic examination showed that the media were perfectly trans-
parent, and oblique illumination proved that the iris was nor-
mal in color and reaction. Both optic discs were of a dirty
grayish-white, and in the left eye the outline of the papilla was
ill-defined and at places swollen, as is met with after a neuritis.
In both discs there was a deep, overhung, almost glaucomatous
excavation, with pulsating veins, but no pulsation in the arte-
ries. In the L. E., in the region of the macula, was a large, ir
regular retinal haemorrhage, of the apparent size of two or
three papillae, with its long diameter vertical and of a different
tint in different portions, showing that there had been several
extravasations at different dates. The center was evidently the
* Read before the American Ophthalmological Society, July 15, 1886.
August 8, 1885.]
BULL: UNILATERAL TEMPORAL HEMIANOPSIA.
151
oldest in date, and the blood had been partially absorbed, giving
here and ther« a glimpse of white sclera showing through an
atrophied choroid. The rest of the fundus in both eyes varied
but little from the normal in its appearance. The tests for
color-blindness showed that in the L. E. the color-sense was
defective for all but blue, while in the nasal half of the field of
the R. E. it was normal though sluggish. The tension was nor-
mal in both eyes, Fig 1.
the field, but there was no change in the ophthalmoscopic ap-
pearances, except a gradual absorption of the extra vasated blood
in the region of the macula, and no recurrence of the haemor-
rhage.
Case II. — Unilateral Irregular Hemianopsia, with Concen-
tric Limitation of the Field of Vision of the Same Eye. — Mr.
D. W., aged sixty, was first seen by me on March 27, 1885, and
gave the following history : On Christmas-day, 1884, while
Fig. l.
Between June 28, 1884, and March 24, 1885, I saw the pa-
tient at intervals of three or four weeks, but never discovered
any change in the condition of the eyes. On the latter date he
complained of seeing what he called a " ball of fire " at times
standing on a street-crossing, he was knocked down and tram-
pled upon by a horse. When picked up he was unconscious, and
there was a large laceration of the scalp covering the frontal
bone above the left eye. He was carried in an ambulance to
Fig. 2.
in front of the L. E., of transient duration, which was always
followed by a spiral or corkscrew appearance of light, which
lasted some seconds. In testing his vision in L. E. at this date,
I found that it had risen to eccentrically in the nasal half of
his home, and, in the transit, regained his consciousness, so that
on arrival at his residence he got out with assistance and
walked up-stairs to his bedroom. He then again became un-
conscious, and remained either semi-comatose or delirious tor
152
HOWE: . THE EFFECT OF COCAINE UPON THE HEALING OF WOUNDS. [N. Y. Med. Jour.,
7°" B — IK 11
Fjg. 3.
four weeks. There were also two ribs on the right side frac-
tured at the time of the accident. An examination of the
scalp-wound, which was of an irregular shape and about three
inches long, showed that it ran from above, close to the hairy
scalp, downward and inward toward the median line of the left
eyebrow. Beneath this laceration was a depressed fracture of
the skull of some considerable extent. The patient was not
trephined, but was treated mainly on the expectant plan. Ery-
sipelas of the scalp developed within the first week, beginning
at the wound and extending all over the face and scalp. Both
eyes were closed by the swelling of the eyelids, and this lasted
for several weeks. When he regained complete conscious-
ness, and the swelling of the eyelids had disappeared, he no-
ticed that he could not see anything on his left side if the
right eye wTere closed, and this condition remained unchanged
till I saw him. In addition to the left temporal hemianopsia,
he complained that, whenever he attempted to write, every-
thing swam before him, but said that he could read with
ease for any length of time without fatigue. He had always
been hypermetropic, but had never worn glasses for distant
15 . : „ . *
vision. An examination showed V = — + in both eyes, and
15
with Sph. + D 2 = — +. He also read Sn. D = 0-25 at 10"
15
with Sph. + D 4. An examination of the field of vision showed
that it was perfectly normal in the R. E. ; but in the left eye
there was a well-marked, though somewhat irregular, temporal
hemianopsia. The color perception was normal in the R. E.,
and normal in the perfect half of the field in the L. E. An
ophthalmoscopic examination showed on the right side a nor-
mal hypermetropic eye, with clear media; but in the L. E. the
opic disc was white, with clearly defined outlines, and the ar-
teries were reduced in caliber. The tension was normal in both
eyes. There was no tenderness on pressure over the seat of
the fracture in the frontal bone, nor along the course of the
supra-orbital nerve. On the contrary, the patient complained
of a numbness along the course and distribution both of the
supra-orbital and infra-orbital nerves ever since he became con-
scious of his own sensations. This patient was seen by me, at
intervals of a few days, from March 27th to date, and there has
been no change in any of the conditions, except a gradually in-
creasing concentric limitation of the nasal half of the field of
the left eye. His last visit was made on June 22d, at which
time a careful examination was again made of the field, and his
vision also tested. Figs. 2 and 3 show the condition of the field
of the left eye at the date of his first visit, March 27th, and of
his last visit, June 22d ; the latter also shows the gradual con-
centric narrowing of the nasal half of the field. A possible
explanation of the visual defect in this case may lie in an ex-
tension of the line of fracture from the frontal bone through
the roof of the orbit, backward to the optic foramen, and a
consequent injury to the fibers of the optic nerve, which are
distributed to the nasal half of the retina. There seems to be
but little doubt that the amblyopia is progressive, and that the
pseudo-hemianopsia will end in complete amaurosis of one eye.
THE EFFECT OF COCAINE
UPON THE HEALING OF WOUNDS.
By LUCIEN HOWE, M.D.,
BUFFALO.
The anaesthetic effect of cocaine upon the eye, already
so well known, suggests an inquiry as to the influence it
may also have on the healing of wounds. A considerable
time must necessarily elapse before clinical experience can
furnish sufficient data to warrant conclusions which are en-
tirely reliable. Different individuals and the circumstances
accompanying the operations vary so greatly that, in spite
of the many cases already published in which cocaine has
been used, only a series of those exactly similar would fur-
nish an average for just comparison. In certain rather rare
instances, it is true, the same operation is made on each
eye of the same individual at the same time, and in these
the effect of the drug can be tested. But such cases are by
no means numerous. I have, therefore, endeavored to de-
termine its influence upon the healing of wounds by pro-
ducing equal lesions in both eyes of an animal, and then
comparing the one treated with cocaine with the other, either
left to itself or treated with atropine. The principal objects
of this inquiry were to detect any unfavorable influence co-
caine might exert upon such wounds by reason of the irri
August 8, 1885.] HOWE: THE EFFECT OF COCAINE UPON TEE HEALING OF WOUNDS.
153
tation produced, or of the effect upon the nerve supply.
On the contrary, if its action was advantageous, it was im-
portant to determine what parts of the eye it affected, and
if for the iris or any other portion it was as reliable as atro-
pine. It is well to settle such questions as soon as possible
after the discovery of an agent like this, whose anaesthetic
properties naturally excite unguarded enthusiasm or too great
confidence in a really valuable drug. Accordingly, in Oc-
tober last, in the laboratory of Professor Zuntz, in Berlin,
I noted the healing process in wounds as follows :
Rupture of conjunctiva in one rabbit.
Rupture of conjunctiva in two Guinea-pigs.
Abrasion of corneal epithelium in two rabbits.
Abrasion of corneal epithelium in one Guinea-pig.
Abrasion of corneal epithelium in one cat.
Burn of conjunctiva and cornea in two rabbits.
Puncture of cornea in one cat.
Iridectomy, simple, in one rabbit.
Iridectomy, iris being left in wound, in two rabbits.
Iridectomy, iris left in wound, in three Guinea-pigs.
Traumatic cataract in three Guinea-pigs.
It would be unnecessary repetition to rehearse in detail
the healing of each of these wounds, yet a few examples are
not out of place illustrating not only the process of repair
in general, but also the form of record kept in these cases.
In these, the eye treated with cocaine is indicated by " O";
the other by " L." or " R.," as it happened to be left or
right. For convenience, the amount of secretion in the con-
junctiva, or the extent of swelling there or elsewhere, is
indicated in degree — 1 representing the minimum and 3
the maximum.
Ouinea-piy. — Extensive tear in conjunctiva, reaching
from outer to inner canthus.
Day.
.....{
* j
* 1
* {
• i
CILIARY INJECTION.
CONDITION OF
WOUND.
Eye.
Large.
Small.
Degree of
swelling.
c.
2
4
2
Closing.
L.
2
4
2
C.
1
2
2
a
L.
3
2
tt
C.
1
1
2
Closed.
L.
2
2
4(
C.
2
1
L.
2
1
C.
2
None.
L.
2
u
C.
Normal.
tt
L.
it
It
Two-per-
cent, solu-
tion used.
- 5 times.
• 6 times.
• 5 times.
- 5 times.
5 times.
Small White Rabbit. — Scrape off epithelium of cornea
in each eye from a spot measuring two by two millimetres.
CILIARY INJECTION.
No. of times
Day.
Eye.
CORNEA.
l-p.-c. sol'tion
Large.
Small.
of cocaine
was used.
~\
*•)
C.
L.
C.
L.
2
2
2
2
4
5
4
2
Epithelium partly renewed.
Epithelium entirely "
Normal.
11
1 ■
! •
M
C.
L.
1
2
1
II
tt
H
1
Comparison of Cocaine with Atropine in the Healing of a
Bum with Lime, involving Conjunctiva and Cornea of a
Rabbit. — A sufficient amount of unslaked lime was placed
on the upper half of the conjunctiva and cornea to produce
an eschar on all the palpebral and ocular portions of the
former, and also to whiten the latter over a space measuring
five by six millimetres. Exactly the same was repeated in
the other eye, and both were thoroughly washed with dis-
tilled water, to remove all remaining particles of lime. A
two-per-cent. solution of cocaine was then dropped into the
right, and one of atropine, of the same strength, into the
left.
CONJUNCTIVA.
CILIARY
a.9
1%
i ,
a a
INJECTION.
„ a
° g
CO
u O
arge.
mall.
pacit
corn
mm.
d "*
H"
.2 P.
«
3
.00
00
03
O
a
c.
Open.
3
3
10
13
6x5
H
L.
H'f-open
3
3
12
9
5x6
8
c.
Open.
H'f-open
2
2
9
10
5x4
L.
3
3
10
9
6x6
8
c.
Open.
CI
1
1
9
8
3x2
7
L.
3
3
10
9
5x4
8
c.
1
10
2x2
7
L.
3
2
8
11
4x3
9
c.
2
8
2x2
6
L.
2
1
6
12
2x3
8
c.
1
8
lxl
6
L.
4
10
2x2
8
c.
4
6
L.
2
10
2x2
8
c.
2
5
L.
6
2x2
7
C.
1
5
L.
2
2x2
7
C.
5
L.
2x2
8
O, o
6 times.
3 times.
5 times.
2 times.
3 times.
t 3 ti
times.
3 times.
3 times.
3 times.
Small Cat. — Puncture anterior chamber of each eye,
evacuating entirely the aqueous humor, and allowing iris to
engage in the wound. Right meanwhile under the influence
of cocaine, and subsequently treated with it.
Day.
Eye.
Conjunc-
tiva.
Normal.
CILIARY INJEC-
TION.
Large. Small.
Nor
Nor
Nor
Nor
mal.
mal.
mal.
mal.
Dull spot in
cornea.
2x2| mm.
3 x 2| mm.
) As on (
S 1st. }
) Barely
) visible. '(
\ " I
Normal.
Wound.
Closed.
Open.
Closed.
Opened.
Closed.
Opened.
2-per-cent.
solution of
cocaine.
9 times.
times.
I 6 tir
j- 5 times,
j- 5 times.
|- 4 times,
j- 4 times.
|- 3 times.
| 3 times.
Large Albino Rabbit. — Two-per-cent. solution of cocaine
dropped into the right until conjunctiva and cornea were
fully under its influence and pupil measured -009 millimetre
in transverse diameter. An iridectomy was then made, and
154
HOWE: TEE EFFECT OF COCAINE UPON THE HEALING OF WOUNDS. [N. Y. Med. Jodk.,
the two ends of iris allowed to remain in the wound. Ex-
actly the same operation was made on the left without co-
caine, the corneal wounds, and pieces of iris removed from
each, being as nearly as possible of precisely the same size.
CILIARY IN-
PUPIL.
Day.
Eye.
Conjunctiva.
JECTION.
Upper part of
cornea.
Wound.
Anterior chamber.
lrin.
2 per cent,
solution of
Large.
Small.
Size.
cocaine.
f
i
i
Much swollen.
1
4
TV. 11
Dull.
Open. Iris prolapsed.
Blood in upper half.
mm.
•005
Swollen.
\ 1
f
T
Ld.
2
3
" " half.
"
t
2
rt
Less
3
2
Closed. " "
" " quarter.
Less swollen.
i
T
L.
2
8
Open. " "
" " half.
*
C.
Normal.
3
2
Clearer.
Closed. "
" " eighth.
"
As on 2d.
> 2
L.
4
6
Dull.
Open. " "
" " half.
I
C.
3
2
Still more clear.
Closed. "
" " eighth.
•008
a ll
L.
4
6
Clearer.
II II II
" half.
•005
it II
\ 4
•
C.
i
o
a
As on 4th.
Blood all absorbed.
Normal.
' 2
L.
3
6
Still more clear.
Blood. Lymph in \.
tt
As on 2d.
6 4
C.
•1 V
1
As on 4th.
As on 5th.
Normal.
[ 2 •
L.
2
3
" 5th.
11 (1
it
Still less swollen.
1 j
C.
2
" 4th.
ii
Normal.
L.
4
" 5th.
II If
II
t 2
'\
C.
2
" 4th.
II
L.
C.
L.
2
1
2
" 5th.
Cicatrix only.
As on 5th.
a II
II a
't
'l
ii
it
!- 2
i 2
H
C.
L.
Cicatrix only.
<« ,i
'<
'.
ii
f 2
Large Brown Rabbit. — A linear wound at the cornea-
scleral margin, six millimetres long, was made in the left,
and the prolapsing iris allowed to remain. Exactly the same
operation was made on the right. A piece of cotton was
placed on each eye, that of the left being saturated with a
two-per-cent. solution of cocaine, and that on the right
with water only. In order that both might be kept moist,
they were then covered with thin India-rubber, and the ani-
mal placed with his head resting easily, b«t firmly, so that
the covering could not be scratched off.
CILIARY IN-
Eye.
Swelling of
JECTION.
Cornea.
Wound.
Anterior chamber.
PUPIL.
Swelling of iri^.
Cocaine,
Conjunctiva.
2 per cent.
Large.
Small.
Size.
Form.
3
8
10
Dull above.
Open.
Small clot above.
mm.
6
Regular.
3
1 10 times
R.
3
8
10
a
Small clot above.
4
Irregular.
3
C.
2
6
7
Clearer.
Closed.
Smaller.
6
Regular.
2
j< 3 times.
R.
3
V
8
Dull above.
4
Irregular.
3
C.
Normal.
3
4
Clearer.
ft
Clot barely visible.
6
Regular.
1
1 4 times.
R.
2
6
8
ii
it
As yesterday.
3
Irregular.
3
C.
Normal.
2
4
Normal.
ii
Normal.
6
Regular.
Normal.
j- 3 times.
R.
3
4
Almost normal.
a
As on 2d day.
4
Irregular.
2
C.
1
2
Normal.
Normal.
6
Regular.
Normal.
j- 3 times.
R.
1
3
it
As on 2d day.
4
Irregular.
2
C.
1
1
it
a
Normal.
6
Regular.
Irregular.
Normal.
1 3 times.
R.
Z % '»
3
As on 2d day.
4
C.
1
ii
>■ it
Normal.
6
Normal.
ii
1 3 times.
R.
3
ii
it
Band of lymph.
4
Irregular.
ii
C.
Nor
mal.
Ii
a
Normal.
Norimal.
R.
Nor
mal.
II
a
Band of lymph.
4
Irregular.
No attempt has been made in any systematic manner to
verify these experiments by a similar series upon the human
subject. One is not justified in subjecting an eye recently
operated upon for iridectomy, for example, to the manipu-
lation, or even violence, which such an exact examination
often demands, but the great majority of clinical experience
thus far seems to be in perfect accord with the results reached
by experiments upon the animals mentioned.
These conclusions may be briefly stated as follows :
1. In lesions of the conjunctiva, perfect solutions of the
hydrochl orate of cocaine have no appreciable effect, bene-
ficial or otherwise, upon the healing process. When the
solution is imperfect, a slight additional hypersemia is pro-
duced, which persists longer than in the other eye, but this
is ordinarily of no practical importance.
2. In lesions of the cornea it has a beneficial effect, like
other mydriatics, but inferior to that of atropine. In im-
perfect solutions a perceptible abrasion of the epithelium
is produced, and, though this is quickly renewed, the heal-
ing is thereby delayed by the cocaine.
3. In wounds of the iris the mydriatic action of co-
caine is evident ; but here again it is inferior to atropine,
and is of little value in detaching firm synechise. Imper-
fect solutions, however, do not appear to hinder the healing
process any more than when applied to the conjunctiva or
cornea. Indeed, as strong mixtures possess decided anti-
septic properties, they would seem to exert a favorable effect
in this respect.
The Death of Prof, von Fehling, of Stuttgart, is announced in our
European contemporaries. He was widely known as the originator of
a ready method of testing for grape sugar in the urine by the use of
what is everywhere known now as " Fehling's solution."
August 8, 1885. J
CRAIG: HYDRIODIC ACID IN RHEUMATISM.
155
SYRUP OF HYDRIODIC ACID
IN ACUTE INFLAMMATORY RHEUMATISM.
By JAMES CRAIG, M. D.,
JEB8ET CITY, N. J.
In an article appearing in the New York " Medical
Record," April 21, 1883, I speak of the manner in which I
was led to the use of this syrup in cases of acute inflam-
matory rheumatism. The object of the present article
is not merely to reiterate what was said in that publication,
but to emphasize my entire faith in the efficacy of this treat-
ment by the citation of cases of cure, and the statement
that I have yet to find a case in which, the syrup being
properly used, it has failed to meet my expectations.
Since the publication of my first article this method
of treatment has been employed by a number of physicians
with success, shortening the duration of the disease, reliev-
ing pain, reducing temperature, and in all cases leaving the
patient without heart complications, the remedy prevent-
ing exudation and organization of plastic material. I order
the syrup in from two- to three-teaspoonful doses, in a wine-
glass of water, every two hour", lessening the dose as im-
provement takes place, and continuing the syrup for about
a week or ten days after symptoms have disappeared, to
insure recovery and prevent relapse.
The old method of treatment by the use of bicarbonate
of potassium is slow, and its continued use brings about a
depraved condition of the system by reducing the amount
of fibrin in the blood and destroying the red corpuscles.
It also acts as an irritant to the stomach, injuring the mu-
cous membrane and causing loss of appetite. The depraved
condition of the blood can be seen in the pale face, pallor
of the lips, and enfeebled action of the heart, requiring
weeks for the patient to recover from the disease and its
treatment. Salicylic acid has had its day and has been
found wanting, being replaced by some with oil of gaul-
theria — salicylic acid in another form.
This acid, from its difficult solubility, allows its crystals
to irritate the throat and stomach, and, in some, occasions
so much vomiting as to render its continued use impossible.
Syrup of hydriodic acid is a good remedy in sub-acute
rheumatism also, but is not so prompt in its action as in
cases of the acute form.
I have tried it in chronic rheumatism, but can not say
that I have observed any good results. In some cases I
use a lotion as follows :
R Liq. plumbi subacetatis 3 ij ;
Tincturae arnica? 3 ij ;
Aquae purse | iv.
M. Sig. Add one part of the solution to three parts of hot
water, and apply saturated flannels to the inflamed joints.
It usually gives immediate relief. This solution is of a
beautiful yellow color when properly prepared.*
* The tincture of arnica should be made according to the United
States Pharmacopoeia, and not by using the fluid extract of arnica
flowers, and making a tincture by the addition of diluted alcohol, as
this tincture makes an unsightly dirty-brown mixture.
The following are a few of the numerous cases of suc-
cessful treatment of acute inflammatory rheumatism by the
use of the syrup of hydriodic acid:
Cask I. — On December 16, 1880, I was called to see Mary
S., aged eight years, who was suffering from a very severe
attack of acute rheumatism. The knees and ankles were very
much swollen, and the pain was so excruciating that she could
not bear the weight of a sheet to touch her legs. Protected
them with a barrel-hoop cut in two and crossed. Prescribed
syrup of hydriodic acid, in teaspoonful doses, every two hours.
The pain was subdued within fifteen bours. Continued treat-
ment for about a week. No relapse.
Case II. — Mrs. E. P. R., aged thirty-five years, was seized
with a chill on January 9, 1883. Began the use of the syrup of
hydriodic acid on the 10th, and continued the treatment, in
three-teaspoonful doses, diluted with water, until the 16th,
when the patient was dismissed cured.
Case III. — Mrs. C. F, O, aged thirty-nine. I was sent for
on March 21, 1883, and found her suffering from acute rheu-
matism; prescribed the syrup in two-teaspoonful doses: con-
tinued treatment to the 29th, when I made my last visit, and
found my patient dressed, sitting up, and free from pain.
Case IV. — B. E., aged fifty-five, a merchant, has had
rheumatism for many years. I attended him with a subacute
attack on the 13th of January, 1884; left him on the 18th free
of pain. The medicine was given in tablespoonful doses, every
two hours, up to this time, when he was ordered to continue
its use in smaller doses and at longer intervals for another week.
On the 4th of April, 1885, I was called to attend him with a
similar attack. Used the syrup. The pain was still severe on
the 5th, so I used the lotion to his hand and knee, which gave
immediate relief. The last visit was made on the 8th, at which
time he was entirely free of pain and swelling.
Case V. — Mrs. L. A., aged twenty-seven, was taken with a
chill, followed with high fever, on the 21st of January, 1885. I
was called on the 22d, and found her suffering with an attack
of acute rheumatism, affecting both upper and lower extremi-
ties. As usual in such cases, prescribed the syrup in three-tea-
spoonful doses, every two hours, using the lotion as well. She
was relieved in thirty-six hours, and was about the house in
one week. Ten days after I made my last visit. Her husband
told me that she had had a relapse from imprudently sitting by
an open window. Medicine was repeated, and in four or five
days she was again free from pain.
Case VI. — W. O, aged twelve years, of stout build, was
seized with rheumatism in knee, ankle, and hand. Saw him for
the first visit on February 20, 1885. I prescribed the syrup in
two-teaspoonful doses, diluted in water (which should always
be done) ; the lotion was also used in this case. My last visit
was made on the 28th, when I left him walking about the
house.
Case VII. — S. G. S., aged thirty-eight, clerk, was seized on
the morning of the 15th of March, 1885. Commenced the use
of the syrup on the evening of the same day; he was free of
pain and swelling on the 16th, and went to his business on the
17th. He has had no return.
Case VIII. — J. O, aged fifty-one, has had chronic rheuma-
tism for more than twenty years. About the beginning of
March, 1885, he was seized with a violent pain in right knee
while walking, followed, after a few days, with heat and swell-
ing. The affected knee was two inches larger in circumference
than the other; the trouble was looked upon as a sprain for
about three weeks, when rheumatism was suspected. Began
the use of the syrup in tablespoonful doses in a gill of water :
he felt relief after the second dose: treatment was continued
150
BOOK NOTICES.— CORRESPONDENCE.
[N. Y. Mkd. Jodb.,
every two or three hours until eight ounces of the syrup were
taken, which removed all further trouhle. No relapse.
CasE IX. — John L., aged forty, coachman, was taken down
on May 4, 1885; his knees were very much swollen and very
painful. He was given the syrup in tablespoonful doses every
two hours, and was able to be around the house in four days
and a half. He had a relapse on the 24th of the same month,
caused by exposure, and was seized with a chill, and again used
the syrup and lotion. Advised the syrup to be continued in
decreasing doses and at longer intervals for a week or ten days.
Cask X. — J. F., aged forty, conductor. I was sent for on
May 29, 1885, and found his right knee and left ankle swollen
and very painful. He also complained of pain in his fingers and
toes. The syrup was given, in tablespoonful doses, every two
hours; the lotion was also used. He was free from pain within
forty-eight hours. Dismissed him on the 3d of June without
pain or ache.
The following cases were kindly furnished me by my
friend, Dr. Conrad Wienges, of this city :
Case I. — August 28, 1883. — P. M., engineer, aged forty-
nine; subacute rheumatism in both knees and ankles. Gave
him two teaspoonfuls of syrup of hydriodic acid every three
hours. Dismissed him September 30th, free from pain or ache.
This patient had several attacks previous to this one, but was
always confined to the house from four to six weeks.
Cask II. — June 16, 1884-— Mrs. L., aged thirty-five; sub-
acute rheumatism in the chest and right shoulder. Two tea-
spoonfuls of syrup of hydriodic acid every four hours. It re-
lieved the pain entirely in twenty-four hours.
Case III. — March 30, 1885. — F. McC, nineteen years old;
worker in tobacco factory; acute rheumatism in both knees
and ankles. He was ordered two teaspoonfuls of syrup of
hydriodic acid, every two hours, in a wineglass of water. At
my next visit, on the 31st, he could flex his knees and move the
foot with comparative ease.
April 1st. — The swelling had vanished and the patient was
sitting up when I called. He was dismissed on the 3d, cured,
and resumed his occupation on the 3d of April.
Case IV.— May 7, 1885.— G. E. P., thirty years old ; deck-
hand ; acute rheumatism affecting his right shoulder and elbow.
The pain was excruciating — so much so tliat one fourth of a
grain of morphine, every hour for four hours, was given to
produce immediate relief. He took two-teaspoonful doses of
hydriodic acid every two hours. At my next visit, sixteen
hours later, the pain had almost disappeared, and he could move
the arm with ease in any direction. On the 9th he was en-
tirely free from pain, and was dismissed, cured, on the 11th.
The following cases were kindly furnished me by Dr.
Baumann, House Physician at the New Haven Hospital,
New Haven, Conn. :
Case I. — M. F. M., Irish, aged twenty-five; single; painter.
Was attacked April 24, 1885, with acute rheumatism in the
ankles and knees, and on the 25th it extended to his shoulders,
elbows, and wrists. Entered hospital this day; temperature
103° F. The pain was so severe that the slightest movement
caused great distress. No cardiac lesions. Ordered syrup of
hydriodic acid, one teaspoonful, every two hours.
28th. — Patient has improved greatly. Temperature 100°;
joints not so painful.
29th. — Improvetnent continues. Patient got up to-day.
May 4th. — He is up and around the wards, and has no pain
in his joints. Treatment continued.
5th. — Discharged cured.
Case II. — P. M., aged twenty-two years; ha9 been under
treatment in the surgical wards since April 28th for gluteal
abscess. He had an attack of rheumatism in both wrists and
hands, and paiu in the chest and back. The pain and swelling
were so severe that he could not bear to be touched. Tempera-
ture 100°. Ordered salicin, grains xx, every three hours, and
sodii bicarb., 3 ss., every three hours.
May 30th. — No marked improvement, and was transferred
to medical wards. Salicin was stopped and he was given
syrup of hydriodic acid, two teaspoonfuls every two hours.
Temperature 101-6°. Morphine, hypodermically, had to be ad-
ministered during the night on account of severe pain.
31st. — Pain diminished ; morphine not required. Tempera-
ture 101-2°.
June 1st. — Patient slept well without the use of anodynes.
Fingers could be moved without pain, but the chest was still
painful.
2d. — Patient comfortable; all pain and inflammation have
disappeared. He fed himself for the first time to-day. Tem-
perature 100°.
5th. — He was transferred to a surgical ward, and syrup
stopped.
8th. — Temperature rose to 100-3°, and another attack threat-
ened. He was given the syrup in the same doses. Next day
temperature fell to normal. The syrup was continued a week,
and then gradually diminished and stopped.
Remarks. — The patient had previously had several attacks
of rheumatism, each lasting from two to four weeks. He had
a mitral regurgitant murmur on admission.
The syrup was tried in a number of subacute cases with
good results, but was unsuccessful in chronic cases.
I hope that I have thus been able to impress upon the
minds of my readers the fact that, by the use of the syrup
of hydriodic acid in cases of acute inflammatory rheuma-
tism, our results will be far more satisfactory, and our cases
less tedious and uncertain.
Dock Botixes.
BOOKS AND PAMPHLETS RECEIVED.
The Overcrowding of the Profession. Extracts from an Ad-
dress delivered March 23, 1885, before the Alumni Association
of the Chicago Medical College, by the President, Dr. E. J.
Doering. Chicago: Clark & Longley, 1885. Pp.8.
Some Interesting Reflex Neuroses, with Treatment and
Comments. By John J. Caldwell, M. D., Baltimore. [Reprint-
ed from the " Virginia Medical Monthly."]
Comsponbpntc.
LETTER FROM WASHINGTON.
The Wales Court- Martial. — Laparotomy for Gunshot Injury. —
Last Yearns Outbreak of Cholera in France.
Washington-, July 31, 1885.
The findings of the naval court-martial before which ex-
Surgeon General Wales was recently tried were made public to-
day. The court sentences him to suspension from rank and
duty for five years on furlough pay, and to retain his present
I number in his grade during that period. The Secretary of the
August 8, 1885.J
LEADING ARTICLES.
157
Navy says: "In expressing its approval of the proceedings,
findings, and. sentence in this case, the department deems it
proper to remark that no dishonest or corrupt act or motive
involving any breach of personal integrity on the part of Medi-
cal Director Philip S. Wales, as chief of the Bureau of Medi-
cine and Surgery, was alleged against him, nor is there any
evidence in the record which would have justified such a charge,
or which tends to cast any reflection upon his personal honesty.
It is equally proper, however, to remark that the charges of
' culpable inefficiency in the performance of duty ' and ' neglect
of duty ' are fully sustained by the evidence. The proof shows
that the established routine of business in the Bureau of Medi-
cine and Surgery, including the various steps required by the
regulations to be taken in making purchnses of supplies and in
paying for the same, was such that the exercise of ordinary
care on the part of Dr. Wales, as chief of the bureau, would
have been sufficient to arrest at an early date, if it could not
have been wholly prevented, the fraudulent acts of his subor-
dinates in the bureau. When he assumed charge of the bureau,
as chief, he became officially bound to enforce, so far as prac-
ticable, an honest as well as diligent performance of duty by his
subordinates, and also became responsible for a proper super-
vision of.their conduct. This he failed to do. The facts and
the degree of punishment proper in the case have received the
careful and laborious consideration of a most eminent court of
naval officers. The proceedings, findings, and sentence of the
court in this case are approved."
Dr. Thomas B. Hood, who has so long and so efficiently per-
formed the duties of Medical Referee of the Pension Bureau,
was removed this week, and Dr. Campbell, of Cincinnati, ap-
pointed in his place. It is difficult to see what public policy
could dictate the removal of one so well fitted by education and
long experience to settle the intricate and far-reaching questions
submitted to the medical branch of the bureau.
Dr. C. V. N. Callan, of the Providence Hospital staff, has
been seriously ill for the last month, and his friends have feared
that his return to duty would be permanently prevented.
Laparotomy with suture of the intestines was recently per-
formed at the Providence Hospital by Dr. John B. Hamilton.
The patient, a young mulatto, was shot in the abdomen three
weeks ago. The wound was inflicted by a pistol carrying a "32
caliber ball. The missile severed a small artery in the mesen-
tery, and made eleven wounds in the small intestines and two
in the ascending colon, and remained in the bowel. The opera-
tion was performed three hours after the accident. The artery
was tied and the wounds were stitched with Lembert's suture.
Fasces were passed by the natural channel on the seventh day,
and on the twentieth day tlje patient was allowed to sit up, the
abdominal wound having healed. The ball was passed with the
fasces on the twelfth day.
Consul Mason, in a recent report to the State Department
on the last year's outbreak of cholera at Marseilles and vicinity,
states that it is now apparently settled that the cholera of 1884
was kindled at Marseilles by the clothing brought to that city
in the trunk of a young student coming from the Lycee at
Toulon.
In regard to the outbreak at Omagues, in the Department
of Basses- Alpes, he states that "l on the 10th of July, 1884, there
arrived at Omagues a young servant-girl who had been in ser-
vice at Marseilles. Soon after her arrival she washed some linen,
which had been in contact with a cholera patient at Marseilles,
in the Jabron, a creek which supplies the village with water.
From that imprudence sprung the contagion which decimated
that unfortunate community and spread death throughout the
valley of the Jabron below Omagues. while the inhabitants of
the same valley above the village escaped."
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, AUGUST 8, 1885.
VACCINATION AFTER THE BEGINNING OF SMALL-POX.
Some weeks ago, commenting on a paper, by Dr. Eccles, of
Brooklyn, published in this journal, we had occasion to express
an opinion which we then supposed, and still believe, to be sup-
ported by overwhelming testimony, to the effect that it was
useless to vaccinate a person already affected with small-pox.
We were aware that an impression to the contrary existed in
the minds of many of the profession, but we were quite unpre-
pared for such statements as we find in a report by Dr. J. H.
Rauch, the able and painstaking secretary of the Illinois State
Board of Health, submitted to the board at its quarterly meet-
ing, held July 2 and 3, 1885. Dr. Rauch quotes from previous
published writings of his own as follows: " It has now come to
be understood that vaccination has a positive therapeutic value,
as well as prophylactic power, and where it is too late to exert
the latter there may still be sufficient time to make the former
available, provided the virus used act promptly. Thus, if a
patient be vaccinated during the febrile stage, and the vaccina-
tion progress normally — there being nothing antagonistic be-
tween the two diseases, variola and vaccinia, to prevent such
normal progress — the areolar stage of vaccination will be
reached before the dangerous tenth day of the variolous dis-
ease; and, as has been, repeatedly witnessed, the graver disease
will be aborted, jugulated, or materially modified." Again, he
says: " It is never too late to vaccinate."
This is a question that only observation can settle, and our
conviction is that observation did settle it long ago. The late
Mr. Marson, whose experience was simply enormous, is quite
explicit on this point. In his article on Small-pox, in Reynolds's
"System of Medicine," he says: "Suppose an unvaccinated
person to inhale the germ of variola on a Monday ; if he be
vaccinated as late as on the following Wednesday, the vaccina-
tion will be in time to prevent small-pox being developed ; if it
be put off until Thursday, the small-pox will appear, but will be
modified ; if the vaccination be delayed until Friday, it will be
of no use, it will not have had time to reach the stage of areola,
the index of safety, before the illness of small-pox begins; this
we have seen over and over again, and know it to be the exact
state of the question. Re-vaccination will have effect two days
later than will vaccination that is performed for the first time,
because re-vaccinated cases reach the stage of areola two or
three days sooner than in those persons vaccinated for the first
time."
Marson's article has been widely read, and the particular
statements we have here reproduced have been extensively
quoted, without, so far as we are aware, the accuracy of the
latter having ever before been challenged by a competent ob-
158
MINOR PARAGRAPHS.
(N. Y. Med. Jocb.,
server. But Dr. Rauch does not rest his contention on theory
or dicta; he adduces certain facts that have come to his own
knowledge. These facts relate to a recent outbreak of the dis-
ease in Mound City, Illinois, in which one hundred and forty-
four cases occurred. Of those attacked, one hundred and
twenty had never been vaccinated prior to actual exposure.
After exposure to cases in their respective families, fourteen of
this number were vaccinated — the exposure having lasted from
three days to "about a week." Of the remaining one hundred
and six, thirty-eight died, the mortality rate being 35-84 per
cent, of the wholly unvaccinated. Only one ("a confirmed
epileptic," twenty-five years of age, vaccinated in childhood)
died, out of the thirty-seven vaccinated before exposure — the
mortality rate in this class being, therefore, less than three one-
hundredths of one per cent. All the fourteen who were vacci-
nated only after exposure recovered. Interesting statistics are
then given as to the average duration of the disease in the sev-
eral classes.
These statements appear to be very much to the point, and,
however at variance they may be with general observation, we
are disposed, considering the high source from which they
emanate, to look upon them as of great importance. There is a
point, however, on which more specific information would be
of value — as to how many of the fourteen had been exposed
for only three days, and how many for "about a week," before
being vaccinated. Moreover, it is not certain that a person
necessarily imbibes the cyntagium the first day that he is ex-
posed to it, or the second day, or any particular day. Nor does
it appear that any of the fourteen had shown signs of actually
having the disease before they were vaccinated. Much as we
defer to Dr. Rauch's judgment, therefore, we can not admit
that in this instance the facts sustain his statement that "it is
never too late to vaccinate."
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Health Department for the following
statement of cases and deaths reported during the two weeks
ending August 4, 1885 :
DISEASES.
Week ending July 28.
Week ending Aug. 4.
Cases.
Deaths.
Cases.
Deaths.
0
1
0
0
16
6
27
5
29
6
23
4
Cerebro-spinal meningitis. . . .
'2.
1
2
2
34
'fif
21
4
34
21
33
17
Small-pox
1
1
2
0
The Health of the State of New York.— The State Board
of Health's " Bulletin " for the month of June shows a total
reported mortality of 6,204, of which 40 per cent, were of in-
fants. The proportion of deaths in each thousand was 238-55
from zymotic diseases, 109*61 from diarrhceal diseases, 5T42
from croup and diphtheria, 103-64 from acute respiratory dis-
eases, and 1 31 "20 from consumption.
The Health of Foreign Cities. — We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office August
4th : Cardenas, Cuba. — For the week ending July 18th : Free
from epidemics; no cholera or yellow fever. Curacoa, W. I. —
For the same week: No cases of infectious disease. Havana,
Cuba. — For the week ending July 22d : About 22 cases and 3
deaths from yellow fever; typhoid fever prevalent. Matamas,
Cuba. — For the same week : No cholera or yellow fever; inter-
mittent fever prevalent. St. Thomas, W. I. — For the second
quarter of 1885: 4 deaths from yellow fever among soldiers in
garrison prior to May 1st, when detachment was removed ; no
cases since. June 23d, quarantine was established against all
Spanish ports, and the importation of rags, padding, wool, hair,
and hides prohibited. Laguayra, Venezuela. — For the week
ending July 18th: Free from infectious diseases. London, Eng.
— For the week ending July 11th : 101 cases of small-pox, and
21 deaths; 101 deaths from diarrhoea and dysentery, and 3 from
simple cholera. Paris, France. — For the week ending July
18th: Small-pox, 41 cases, 1 death; typhoid fever, 199 cases,
38 deaths. During the week ending July 11th there were 40
cases of small-pox and 5 deaths; typhoid fever, 146 cases and
27 deaths. Lisbon, Portugal.— May 9th to 23d : 6 deaths from
small-pox; otherwise free from infectious diseases. Trieste,
Austria. — For the week ending July 4th : 3 deaths from small-
pox; diphtheria prevalent. Valencia, Spain. — For the week
ending July 11th: Cholera, 1,747 cases and 964 deaths. The
epidemic is reported as spreading still, but becoming less viru-
lent. Venice, Italy. — For the week ending July 4th : 5 deaths
from small- pox ; diarrhceal diseases prevalent. Bombay. India.
— For the week ending June 23d : 2 deaths from cholera : gen-
eral sanitary condition good.
English Comments on the Congress Question.— Until
now, the " Medical Times and Gazette" has been almost the
only European journal to give its readers anything like an ade-
quate idea of the deplorable status of the matter of the Inter-
national Medical Congress in this country. In its issue of July
25th it quotes from a number of American journals, and says
editorially : " The leaders of the profession both in Boston and
Baltimore have followed the lead of the Philadelphians and
withdrawn from the Congress, and it is not unlikely that their
example may spread to other cities, though indeed enough has
already been done to turn the meeting of 1887 into what an
American contemporary, drawing its illustration from our com-
mon history, appositely terms a ' rump ' Congress. The only hope
is that the American Medical Association will be startled back
to its senses by the strong and decisive action of the profession
in Philadelphia, Boston, and Baltimore, and will make haste to
retrace its steps. It may be taken for granted that not even the
leaders of the malcontents, and certainly not the members of
the association at large, realized that the result of their action-
would be destruction to the Congress of 1887 and danger to its
successors. Such an event was probably far from their calcu-
lations. They simply reckoned without their host, i. e.. their
leaders, and if they are wise they will cast another reckoning,
this time with due regard to the said host."
Homoeopaths in the British Medical Association.— In
the report of the Council, presented at the recent meeting at
Cardiff, and published in the " British Medical Journal," we
find this statement : "The Council have had under their con-
sideration the subject of admission and retention of homoeopaths
as members of the association during the pa«t year. An inquiry
has been made throughout the thirty-three branches, and the
result has been that there is evidence to the effect that a large
majority of the members are adverse to the admission of homoeo-
paths as members, but an equally large proportion are opposed
to the idea of the expulsion of those members who have already
gained admission into the ranks of the association."
August 8, 1885.1
LETTERS TO
THE EDITOR.
159
The Lehigh Valley Medical Association will hold its
fifth annual meeting at Quakertown, Pa., on Wednesday, the
19th inst. The programme includes an address on "The Proper
Organization of Local Boards of Health," by Dr. Benjamin Lee,
and one on "The Treatment of Joint Diseases by Rest," by Dr.
De Forrest Willard.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from July 26, 1885, to August 1, 1885 :
Bill, Joseph H., Major and Surgeon, U. S. A. Died at Yon-
kers, N. Y., July 21, 1885.
MoDougall, Charles, Lieutenant-Colonel, TJ. S. A. (retired).
Died at Fairfield, Va., July 25, 1885.
DeWitt, Calvin, Captain and Assistant Surgeon. Promoted
to major and surgeon, vice Bill, deceased, to take effect from
July 21, 1885.
Ives. Francis J. Appointed assistant surgeon with rank of
first lieutenant, to rank as such from July 25, 1885.
Girard, A. C, Captain and Assistant Surgeon. From Depart-
ment of the East to Department of the Columbia. S. O.
170, A. G. 0., July 27, 1885.
Ebert, R. G., Captain and Assistant Surgeon. From Depart-
ment of the Columbia to Department of the East. S. O.
170, A. G. 0., July 27, 1885.
Tesson, L. S., Captain and Assistant Surgeon. Ordered from
Fort Stockton, Texas, to Fort Davis, Texas. S. O. 90, De-
partment of Texas, July 27, 1885.
Carter, W. F., Captain and Assistant Surgeon. Ordered for
duty as post surgeon, Fort Stockton, Texas. S. O. 90, De-
partment of Texas, July 27, 1885.
Appel, A. H., Captain and Assistant Surgeon. Ordered for
duty with U. S. troops, forming portion of guard of honor
over remains of Ex-President General Grant, at Mt. McGre-
gor, N. Y. S. O. 36, Division of the Atlantic. July 29, 1885.
Gorgas, William C, Captain and Assistant Surgeon. Granted
leave of absence for two months, to take effect about August
in, 1885. S. O. 169, A. G. O., July 25, 1885.
Society Meetings for the Coming Week :
Monday, August 13th: Boston Society for Medical Improve-
ment; Gynaacological Society of Boston; Burlington, Vt.,
Medical and Surgical Club ; Norwalk, Conn., Medical Soci-
ety (private).
Tuesday, August llfth: Medical Society of the County of Rens-
selaer, N. Y. ; Newark and Trenton, N. J., Medical Associa-
tions (private).
Wednesday, August 15th: New Jersey Academy of Medicine
(Newark).
Thursday, August 16th: New Bedford, Mass., Society for Medi-
cal Improvement (private).
f fttcvs to tbc Editor.
THE MEDICAL MUDDLE.
Fort Buford, D. T., July 25, 1885.
To the Editor of the New York Medical Journal :
Sir : It is not graceful to apply such terms as " organized
villainy " and " crowning act of infamy " to the American Medi-
cal Association, as was done in your editorial of July 11th.
Let us see : " Villany, n. Extreme depravity. Atrocious wick-
edness." "Infamy, n. Total loss of reputation." Is our great
A. M. Ass. depraved or totally wicked, or has it lost anything i
I once knew a good old man who was noted for wealth and
Christian meekness in a community where both were scarce.
He had a pet chicken, which was being raised "by hand," as it
were. This chicken, early in its career, showed a strong ten-
dency to consider itself " one of the family." Its frequent
visits to the parlor made it a disturbing element. On the occa-
sion of one of these visits, the old man, who had been dozing
before a bright fire, called a negro servant to drive the chicken
out. The servant, with white apron spread before him, made a
dash at the chicken, and so startled it that it ran into the blaz-
ing tire upon the hearth. The old gentleman gazed upon the
catastrophe with more of horror than commiseration depicted
upon his features, and, after mature deliberation, remarked with
great gravity, " You're a fool ! " It was the first and only piece
of severity he was ever known to be guilty of, although the
owner of two or three dozen slaves.
I don't know why the action of the A. M. Ass. should recall
this incident of my childhood. The feelings with which I have
contemplated that action have not been all commiseration, but
"organized villainy" and "crowning act of infamy " were
never suggested to my thought. Instead of guile, I have no-
ticed, besides bile, that absence of intelligent comprehension
which led the chicken — but I have said I did not know why
the action of the A. M. Ass. reminded me of the chicken inci-
dent.
I had supposed that the idea of the Congress was an asso-
ciated effort of the leading medical minds of the world to evolve
something by which mediocrity might be benefited, and the
leading minds refreshed and encouraged for still greater achieve-
ments. The idea that local geographical divisions in our coun-
try could have anything to do with such a Congress was, to me,
the embodiment of — why did you not, by the way, think of
that word imbecility? It would have obviated the necessity of
such strong terms as " villainy," " infamy," etc.
I could never understand why well-earned obscurity should
desire to obtrude itself upon the assembled wisdom of the
world. I yield to no man in the possession of that amiable
quality ; but, before I would allow myself thrust into such com-
pany in any official capacity, I would apply for a " sick leave."
If left without constraint, I might slide in at a side-door and
listen to the speeches in German and Russian, but nothing
more.
Large bodies are apt to act with more difficulty than wis-
dom, and are only necessary when the political and religious
liberty of all are concerned. The original committee, being in-
telligent and wieldy, was doing its work well. If it had been
let alone, gratifying success seemed reasonably sure. As mat-
ters now stand, ignoble failure is much to be feared. There
ought to have been no t wo opinions about our duty, or the duty
of the committee, to put forward: 1. Our men of international
reputation. 2. Our men of national reputation. 3. If more
were needed to round off with, the best local material. But no
geographical thought should have entered any man's head, nor
would have, if nature had not abhorred a vacuum.
S. S. Turner, M. D., A. A. Surgeon, TJ. S. Army.
THE DISINFECTION OF RAGS.
August 5, 1885.
To the Editor of the New York Medical Journal:
Sir: In the "Medical Journal" of August 1st Major Stem-
berg states, in a letter addressed to you, that he has nothing to
do with the fight between the paper manufacturers and the
health officers, who insist upon the disinfection of rags from
cholera-infected districts. I am not aware that any such fight
exists.
160
PROGEEDINOS
OF SOCIETIES.
[N. Y. Med. Jouh.,
They (the paper makers) not only do not object to raps from
infected ports being disinfected, but would prefer (in deference
to public opinion) that their importation (from such ports)
should be entirely prohibited. The only contest the paper
manufacturers have with the health officers is about rags from
healthy ports. Last winter a patent was obtained for a process
for disinfecting rags ; a few days afterward an order was issued
that all rags shipped after January 1st should be disinfected ;
this order was revoked by the present Secretary of the Treas-
ury.
No such patent or order was ever before issued in this or
any other country. What the paper makers object to is that,
while there is no case on record of cholera having been con-
veyed in rags, they should be compelled to subject their mate-
rial, under the pretext that it is dangerous, to an expensive and
(as they believe) injurious and unnecessary process.
The estimated annual consumption of rags in this country
is 270,000 tons. The charge for " disinfecting " is $5 a ton ;
this would make quite a handsome revenue.
By publishing this you will much oblige yours, etc.,
Augustine Smith,
Vice-President of the American Paper- Makers'1 Association.
DR. DIXON JONES'S UTERINE APPLICATOR.
Brooklyn, August 3, 1885.
To the Editor of the New York Medical Journal:
Sib : The cut accompanying the description of my applicator,
in your issue of August 1st, entirely fails to give a proper idea of
the instrument. By some mistake, the instrument-maker failed
to send the cut intended to accompany the description. The
forceps has a double curve — one corresponding to that of the
normal parous uterus, the other a compensatory pelvic curve,
which facilitates any manipulation in which it is used.
Yours, very respectfully,
C. N. Dixon Jones.
JUiotccbinjgfs of Smuius.
NEW YORK OBSTETRICAL SOCIETY.
Meeting of February 17, 1885. -
Dr. Walter R. Gillette in the Chair.
Recurrent Tumor of the Breast. — Dr. B. F. Dawson
showed a tumor which he had removed a few days before>
Five years ago an enlargement appeared in the patient's right
breast. The mass was excised, but soon recurred, so that it
was necessary to repeat the operation seventeen times ; the last
operation was performed about a year ago. Soon after that the
patient began to be troubled with excessive leucorrhcea, and for
six months past she had had repeated haemorrhages, attended
with a gradual decline in her health and strength, so that a sus-
picion of malignant disease of the uterus was aroused. Six
months ago there was a recurrence of the mammary growth at
the site of the last operation. Dr. Dawson saw the patient one
month ago. The tumor then presented the appearance of a
large dark bleb. The os uteri was patulous and its edges were
ragged, but there was no haemorrhage at that time. The uterus
was movable, and there were no evidences of infiltration around
it. Dr. Sands now saw the patient in consultation, and re-
garded the tumor as a myxo-sarcoma. She improved so much
that Dr. Dawson operated about three weeks ago. She had
recovered rapidly and was now able to walk about. Her uter-
ine condition had improved, but, if the haemorrhages returned,
he would consider the question of a radical operation. ( A sub-
sequent microscopical examination showed epithelioma of the
cervix.)
Sarcoma of the Uterus. — Dr. Dawson also showed a quan-
tity of soft brain-like material which he had removed from the
uterine cavity of a patient at the Woman's Hospital. She had
had constant leucorrhcea for four years, with repeated haemor-
rhages during the past three months. The discharge always had
a very offensive odor. He found an irregular patulous os, from
which protruded a dark, friable mass, which bled easily on
being touched. The uteru.s was enlarged and soft, but freely
movable. The diagnosis seemed to lie between sloughing fibroid
and sarcoma. The cervix was divided and the interior of the
uterus was thoroughly scraped with the spoon-saw (which was
used as a curette). Although the patient had showed symptoms
of septic poisoning before the operation, she recovered per-
fectly and was now comfortable. It would probably be neces-
sary to remove the uterus eventually.
Dr. Dawson remarked that these cases were both interest-
ing from the fact that if the conditions had been recognized at
an early day much trouble might have been saved.
Dr. H. C. Coe said that he had examined the second speci-
men and found it to be round-celled sarcoma.
Dr. A. Jacobi asked if any enlargement of the axillary
glands had been observed. The reply was in the negative. Dr.
Jacobi said that he had asked this question because he had the
impression that sarcoma was rarely attended by any considera-
ble affection of the neighboring glands. lie further stated that
sarcoma of the uterus sometimes bore a close resemblance to
fungoid growths. He recalled the case of a woman, forty years
of age, from the interior of whose uterus he had removed with
a common soup-spoon a cauliflower mass as large as a man's
fist, which proved to be round-celled sarcoma. No secondary
deposits existed, so far as could be ascertained; in fact, sarcoma
might run a long course without the formation of metastatic
growths.
Dr. P. F. Munde mentioned the case of an Irishwoman who
entered his service at Mt. Sinai Hospital, complaining of fre-
quent uterine haemorrhages and a constant offensive discharge.
The uterine cavity was found to be four inches in depth and
was filled with a soft mass which broke down under the finger.
As the patient was too weak at the time of entrance, he in-
tended to build up her strength and then to scrape out the cav-
ity with a Simon's sharp spoon and subsequently swab it out
with chloride of zinc, but an operation was declined.
Dr. Jacobi asked, with reference to the mammary tumor, if
it was not rather unusual to have a complete absence of glandu-
lar enlargement after the growth had been so frequently re-
moved.
Dr. Dawson thought that perhaps the tumor had always
been removed so early that there was no time for the glands to
enlarge.
A Shot-Perforator.— Dr. C. Cleveland presented a modi-
fied shot-perforator, in which a spring was so arranged that the
shot were disengaged from the pin as the forceps opened.
A Uterine Drainage-Tube.— Dr. W. G. Wylie showed a
uterine drainage-tube of hard rubber for use after dilatation of
the cervix, or whenever it was desirable to maintain patency of
the eanal. He said that he used six sizes of the instrument,
there being three variations in the length and three in the di-
ameter. He maintained the following advantages for the tube:
1. Having a bulbous extremity, it could not slip out of the
canal. 2. The groove along its side allowed of free drainage.
3. The curve was such that it adapted itself perfectly to the
shape of the uterus. 4. There was a knob at the lower end,
August 8, 1885.]
PROCEEDINGS
OF SOCIETIES.
161
which could he held with a forceps and the tube easily with-
drawn.
Dr. J. B. Hunter asked when this instrument was indicated.
The answer was, when it was necessary either to drain the
uterus or overcome stenosis.
Dr. Mdnde thought that a straight stem could be introduced
perfectly well if the os was dilated thoroughly and the anterior
lip was then drawn down with a tenaculum.
Dr. Hunter remarked that Dr. Sims originally used a straight
tube, but subsequently modified it.
Dr. Dawson and Dr. Perry thought that the cervical mu-
cous membrane might become entangled in the slot at the side
of the stem, so that it would be impossible to withdraw it.
Dr. Wylie said that this never occurred after proper dilata-
tion. He thought that the cervix was stretched during the
attempt to introduce a straight stem. He had been led to
adopt this form of stem from observing how often it was neces-
sary to hold the other varieties in situ by means of tampons.
He was of the opinion that in many cases the plug had not been
passed through the internal os at all.
Dr. Cleveland asked if stems were not sometimes forced
out even after they had been introduced through the os in-
ternum.
Dr. Wylie thought not. He subsequently admitted that
they might be expelled by uterine contractions.
Dr. Munde differed with Dr. Wylie, and thought that he
had frequently introduced laminaria tents through the os and
had seen them come out again, simply because they were slip-
pery.
Dr. Wylie thought that a distinction should be drawn be-
tween slipping and rebounding.
Silvered Copper Wire. — Dr. Hunter showed a specimen
of silvered copper wire which possessed all the advantages of
solid silver wire and yet cost only about one twentieth as much.
It was less brittle than silver.
B. MoE. Emmet, M. D.,
B. F. Dawson, M. D.,
H. C. Coe, M. D., ex officio,
Committee on Publication.
NEW YORK PATHOLOGICAL SOCIETY.
Meeting of June 10, 1885.
The President, Dr. John A. Wyeth, in the Chair.
Exsection of the Knee.— Dr. J. H. Ripley presented an
Italian, twenty-eight years of age, who was admitted into Chari-
ty Hospital September 14, 1882. There was no history nor
evidence of venereal disease. He had always been well until
four years ago, when he had an attack of rheumatism, suffering
continuously from severe pains in the left knee joint, which
was very hot, but not swollen. This attack continued for about
one year, and then disappeared of itself. September 2, 1882,
the patient slipped on a banana-peel and injured the left knee,
which soon increased to twice its natural size, and became very
hot and painful. Twelve days later he entered Charity Hos-
pital, and was treated for rheumatism in a medical ward for
three months, when he was transferred to a surgical ward.
Extension was employed for two months, in conjunction with
the local application of liniments, etc., and internal remedies.
Extension was then discontinued, and a succession of plaster-of-
Paris splints applied, together with the use of electricity, etc.
Although there was absence of crepitus, and several surgeons
were in doubt as to the propriety of exsection, Dr. Ripley con-
cluded to do the operation, as it seemed to offer the patient the
only chance of relief. The bones of the joint were very exten-
sively diseased. The patient made a good recovery, with two
inches shortening. The interest of the case centered in the fact
that the man had suffered for nearly three years with inflamma-
tion of the knee, there being no suppuration, and at the end of
that time the pathological condition was such that several sur-
geons were in doubt as to the propriety of exsection. The rea-
son why friction was absent was that at no one point were both
of the opposing bones roughened. A second point of interest
was the illustration of the reparative power of diseased bone.
A third point of interest concerned the use of wires. Dr. Rip-
ley thought they did little or no good, and they gave him a
great deal of trouble in removing them. He referred to another
case of exsection under like circumstances, done about ten years
ago, in which the patient was longer in recovering from the
fact that the bones were not made immovable.
The President remarked that this case afforded strong evi-
dence in favor of exsection as against the old method of treat-
ment by amputation. In the latter case the death rate had been
placed at twenty-five per cent. He had not seen a case in which
death resulted from exsection. He referred to some cases in
which he had done exsection the past winter, and said he did
not use wires, for the limb could be rendered immovable with-
out them. If wires were used, it was unnecessary to remove
them afterward.
Suppurative Endocarditis.— Dr. R. Van Santvoord pre-
sented the heart and great arteries removed from the body of a
man, forty-six years of age, who was admitted into the hospital
March 28th. His father had died suddenly after a few weeks' ill-
ness, the nature of the trouble being unknown. His mother
had died suddenly of heart disease, aged sixty-three. The pa-
tient, when a child, had had measles, scarlet fever, and small-
pox, had had a chancre without secondary manifestations, and
had been a hard drinker. He had suffered from rheumatism
and from swelling of the feet at night. There were aortic and
mitral regurgitant murmurs, the apex beating in the sixth inter-
costal space. When admitted, he was suffering from rheuma-
tism, the attacks recurring during his stay, with exacerbations
of temperature, and finally exhaustion. He had become apa-
thetic, and his memory failed. At the autopsy a small bony
growth was found impinging upon the brain between the second
and third frontal convolutions, about half an inch in front of
the ascending frontal. There was a certain amount of pachy-
meningitis haimorrhagica, chiefly over the left hemisphere ; the
membranes were generally opaque ; most of the vessels at the
base of the brain showed considerable atheroma. There were
lesions in other organs, the result of alcoholism, but the lesion
of chief interest existed in the heart. There were the remains
of old pericarditis, the ventricles were somewhat dilated, and
the muscular substance had the gross appearance of fatty de-
generation. On the leaflets of the aortic valve were masses of
vegetation, surrounding two perforations of the valve, of about
the size of a crow-quill. The third leaflet was somewhat athe-
romatous, but had no vegetations. There was also a rough spot
of the size of a three-cent piece on the inner surface of the heart,
forming a pocket. A small mass of vegetations was found on
one of the leaflets of the mitral valve. The aorta showed ad-
vanced atheroma. The sphygmographic tracing had been that
said to be characteristic of a combination of aortic regurgitation
with atheroma of the arteries.
Congenital Deformities.— Dr. A. Jacobi showed a boy,
aged seven years, who presented certain congenital deformities,
but was in normal health. The right upper extremity was
normal. On the left hand there were but three fingers, the
index and little fingers being absent, together with their corre-
sponding metacarpal bones. The left ulna was 14 ctm. long,
and the right one 16-75 ; the left elbow joint was imperfectly
formed, allowing of only partial supination. The lower extremi-
162
REPORTS ON THE PROGRESS OF MEDICINE.
[N. Y. Med. .Jour.,
ties presented symmetrical malformations excepting in the fol-
lowing respects : The left foot was half an inch shorter and was
smaller than the right; the right thigh was longer than the left
by about 4 ctm. The movements of the right foot were much
freer than those of the left. The patella was absent on the left
side, and imperfectly formed on the right. The right leg was
28, the left 27 ctm. in length. On the left foot the second and
third toes were slightly raised. The chest showed some signs
of rhacliitical development, most marked on the left side. The
head and face were nearly symmetrical.
His sister, a baby, aged three years, had a congenital de-
formity of the right leg and foot. The tibia had an anterior
curve, and at about the junction of the middle with the lower
third there was a longitudinal scar half an inch in length. There
was decided eversion of the foot, with absence of the fibula.
There were but two toes, one being the great toe, the other
apparently a blending of two toes. There were three meta-
tarsal bones, the great toe articulating with the first, and the
second toe with the two others. The right limb, down to the
knee, seemed to be perfect. It was impossible to straighten the
leg on the thigh, because of some malformation in the knee
joint. The leg turned outward when it was straightened as far
as possible. The right leg was shorter than the left by an inch
and a half, being eleven inches long. There seemed to be no
anterior tibial artery. The right foot was shorter and smaller
than the left. As to the bones entering into the formation of
the tarsus, it was impossible to state positively, but the cunei-
form bones seemed to be absent. The right patella seemed to
be somewhat smaller than the left, and was placed a little ex-
ternally to the normal position. The three metatarsal bones
articulated with the scaphoid and cuboid. The speaker had
seen as many as three or four cases of absence of the fibula,
there being a scar on the leg, which one might suppose resulted
from an injury at a period of intra-uterine life when the skin
was only partially developed.
Volvulus of the Sigmoid Flexure.— Dr. Frank Ferguson
presented a distended and dried gut, showing volvulus of the
sigmoid flexure. The patient, a Russian, aged thirty-seven
years, had complained for several years of abdominal pains and
cramps, which would pass away to return again. On the 27th
of February last an attack had lasted three days, when he
sought relief in the hospital. It began with a chill, followed
in a short time by nausea and vomiting, there being very severe
and continuous pain in the abdomen. He rapidly failed, and
died four hours after admission. The autopsy showed enormous
distension of the gut, with twisting of the sigmoid flexure, which
was blackened with haemorrhage. The obstruction was com-
plete.
Dr. Waldstein thought it was not infrequent to find at the
autopsies of old subjects, with a large amount of adipose tissue
in the peritonaeum, a turning of the gut, almost amounting to a
complete twist and obstruction, with great distension of the
colon co-existing.
Dermoid Cyst near the Coccyx. — The President presented
a tuft of hairs, obtained in the case of a patient twenty-two
years of age, who came for treatment of a supposed fistula start-
ing eighteen months before in what he called a boil near the
coccyx. The sinus led down to an abscess, and no communi-
cation with the rectum was apparent. A little pimple, looking
like a comedo, attracted attention, and, being explored with a
probe, was found to lead to a small cavity. With a little force
the probe was made to penetrate into the old abscess. In the
cavity was a tuft of hair, resembling that of a camel's-hair
pencil. The President thought it was undoubtedly a dermoid
cyst, and, so far as he knew, the case was unique.
Dr. Ferguson asked if congenital cysts in this locality were
not rather common. He had examined two specimens of con-
genital cysts situated over the sacrum which contained ciliated
epithelium and cholesterin. No hair was present.
Reports on tbe progress of ftlciJtciite.
GENERAL MEDICINE.
By ALEXANDER DUANE, M. D.
The Morbid Anatomy of Diabetes. — The summing up of Windle's
examination (" Dublin Jour, of Med. Sci.") of all accessible records of
autopsies held in cases of diabetes mellitus is that no one lesion is pres-
ent with any degree of constancy, and, further, that no one organ is
involved in more than half the cases in which the condition of that
organ has been ascertained. Thus, in 184 cases in which the brain was
examined, it was found normal in 91, and in the remaining 93 the most
diverse lesions were discovered. Lesions affecting the medulla and the
fourth ventricle were present in 23 of these cases. So, also, among 58
cases in which the spinal cord was examined, only 25 showed any ab-
normity. On the other hand, out of 333 cases, only 75 presented a
normal condition of the lungs, while rather more than one half of the
whole number displayed the lesions of pulmonary phthisis. It is to be
noted that these pulmonary lesions do not appear to be the result of
the deposition of tubercle, and for their origin seem to be dependent
upon some change taking place in the nervous system. Fat embolism
of the lungs, although described by some, seems to be of rare occur-
rence. Enlargement and congestion of the liver are frequent accom-
paniments of diabetes, but the microscopical appearances are not char-
acteristic. The same may be said of the renal changes. The pancreas,
again, was affected in more than half of the cases in which the condi-
tion of the organ was noted, the lesion being usually of an atrophic
nature. Lesions of the other organs are noted, but are still more in-
constant in their appearance. These are all tabulated in considerable
detail in the original paper.
Diabetic Coma. — Lindsay (Ibid.) brings little that is new to add to
our confessedly imperfect knowledge of diabetes. He briefly dismisses
most of the current theories as to the origin of diabetic coma, believ-
ing them all to be unproved, although he inclines most favorably to the
toxaemic hypothesis. His own observations, with those of others, show
that coma terminates about half of the cases of diabetes, being rela-
tively more frequent in the young and in cases of acute coma, more
particularly those uncomplicated by pulmonary disease. [That a rap-
idly fatal course with death from coma is usual in young subjects has
been shown already by Schmitz, who has statistics of six hundred cases
of diabetes.]
A Disease of Auerbach's and Meissner's Plexuses. — Blaschko
('' Arch. f. path. Anat. u. Phys. u. f. klin. Med.") has described two cases,
in both of which there was extreme fatty degeneration of the svmpa-
thetic plexuses in the walls of the intestine (plexuses of Auerbach and
Meissner). Only one case presented a well-defined clinical history, the
symptoms being those of extreme and progressive anaemia and pro-
found disturbance of the digestive functions, with abdominal pain, but
without any characteristic change in the blood suggestive of pernicious
anaemia or of leucocythaemia. There was marked atrophy of the in-
testinal wall, and the fact that in other cases where this atrophy exist-
ed, and where a sufficient cause for its existence was present, no altera-
tion of the sympathetic plexuses was found, seems a proof that the
sympathetic lesion in this case was the cause, and not the effect, of the
intestinal atrophy.
(Edema from Vaso-motor Paralysis. — Jankowski's experiments
upon animals {Ibid.) tend to prove that vaso-motor paralysis is an im-
portant factor in the production of oedema ; and that, while scarcely of
itself sufficient to excite this condition without an accessory hydraemia,
its influence must be called into account for most of the cases of oedema
occurring in cachectic conditions. The fact that transudation from the
vessels may thus be largely dependent upon the state of the peripheral
nerves, and hence upon alterations of the nervous centers affecting this
state, will also serve to explain the existence of urticaria and of the
August 8, 1885.]
MISCELLANY.
163
acute circumscribed oedema of Quincke (acute rheumatismal oedema),
which undoubtedly have their origin in the central nervous system.
Diabetes Insipidus. — Weil (Ibid.) has, with extraordinary patience
snd industry, followed out the family history of a patient afflicted with
diabetes insipidus, and has found that in his case it was undoubtedly
an hereditary malady, many of his ancestors and immediate relatives
being victims to it, or, to use their own phraseology, being u water-
drinkers." The disease first appeared in the family records in the
great grandfather, who had five children, of whom three were affected
like himself. Of twenty-nine grandchildren, seven were " water-drink-
ers " and nine died in infancy, before the disease had a chance to show
itself. There were fifty-six great grandchildren, and twelve of these
were the subjects of diabetes. It is to be remarked that all who
escaped having the disease transmitted the same immunity to each one
of their children and grandchildren ; so that atavism would seem to be
the exception in the transmission of this form of diabetes. The author's
facts, the collection of which must have cost him very great expense of
time and trouble, are summed up in a neat genealogical tree, showing
the relationships between the diabetic ancestor and his ninety descend-
ants, as regards both the ties of blood and the more recondite associa-
tions involved in the transmission of the disease.
Intestinal Neuroses. — Cherchevsky (" Rev. de m6d.") has collected
several cases which he regards as examples of tonic spasm of the circu-
lar muscle-fibers of the intestines. This accident, which occurs more
especially in persons of intellectual'habits and sedentary modes of life,
is characterized by suddenly appearing enormous tympanitic distension
of the abdomen, with a considerable degree of pain and tenderness, a
sense of epigastric oppression and of dyspnoea, violent griping pains
and constant desire to go to stool with inefficient expulsive efforts, and
the passage of only a small amount of fiscal matter in the form of
bullet-like scybala or of small compressed cylinders. These symptoms
last a few hours, or even some days, and then suddenly disappear. In
the intervals between the paroxysms the patients enjoy excellent
health, their appetite is good, and their only complaint is of more or
less persistent tympanites, with constipation and frequent eructations
of odorless and tasteless gas. The paroxysms are induced by intellect-
ual effort, mental excitement, violent emotions, etc. This, together
with the suddenness of the appearance and disappearance of the symp-
toms and the character of the latter, leads the author to the belief that
in this condition we have to do not with a state of intestinal atony, but
with a state of localized intestinal spasm, producing sudden accumula-
tions of gas with the associated phenomena of colic, tenesmus, and
constipation. The results of treatment are corroborative of this view,
as the constipation and tympanites yield readily to opium and bella-
donna, while cathartics, which should ameliorate the symptoms, if due
to atony, only aggravate them.
The Virulence of Tuberculous Matter. — Martin and Parrot (Ibid.),
in experiments which seem to be conclusive, have found that no one of
the so-called antiseptics — carbolic acid, creasote, corrosive sublimate,
bromine, salicylic acid, or oxygenated water — even in the most concen-
trated solutions and the most complete and prolonged contact, can be
relied upon to destroy the virulence of tuberculous matter. The only
agent which acts certainly in this way is heat, and the surest means of
disinfection in a hospital or apartment is the introduction of air heated
to 125° C, and carried into every corner and crevice. But, so far as
any feasible means for attacking the tuberculous organism in the hu-
man system are concerned, the author's experiments are completely
negative.
Diabetic Neuralgia. — The occurrence of neuralgia in diabetic sub-
jects, and depending apparently upon the diabetic diathesis for its ex-
istence, has been noticed by several writers within the last two or
three years. Cornillon (Ibid.) has collected the histories of twenty-two
instances of this association of neuralgia with diabetes ; eight of these
cases, including two contributed by himself, have been very fully de-
scribed ; the histories of the other cases are more meager. The char-
acteristics of diabetic neuralgia, judging from the description of these
twenty-two cases, are well marked, and render the diagnosis of the com-
plaint easy. Such neuralgias are distinguished by their spontaneity, no
cause, either immediate or remote, except the glycosuria, being discov-
erable ; by their intensity, hardly paralleled in any other variety of
pain ; by their tendency to a symmetrical development (noted in eigh-
teen out of the twenty-two cases) ; and by the obstinacy with which
they resist any form of treatment except that addressed to the relief of
the causal condition — the diabetes itself. They show a tendency to
attack the regions supplied by the sciatic nerve, although the face and
other parts of the body are also occasionally affected. They are asso-
ciated with marked tenderness to pressure over the course of the nerve
which is the seat of the pain ; and motion of the muscles in the vicinity
of the nerve, as well as variations of temperature, greatly aggravates
the suffering. The causation of this rather infrequent form of neural-
gia is still obscure. The author rejects the hypothesis of Rosenstein,
that it is due to congestion of the abdominal viscera, on the ground that
the latter is so often present without the co-existence of any neuralgic
or any diabetic symptoms. The theory that it is due to an excess of
sugar in the blood is disproved, he thinks, by the fact that in some of
the cases the glycosuria is very moderate, and that, although in some
instances the intensity of the symptoms is proportional to the degree of
glycosuria, this is by no means the universal rule. Cornillon's own
view, which, we believe to be open to the same objections that he urges
against these other theories, is that diabetic neuralgia is a manifesta-
tion (as he holds diabetes itself to be) of a gouty diathesis, and that
such a neuralgia is the direct result of a condition of uricEemia. The
decision of this question must, however, undoubtedly await more ex-
tended investigation and the analysis of a greater number of cases than
the author has been able to collect.
Pernicious Anaemia in Children. — Kjelberg (" Arch. f. Kinder-
heilk.") describes a case of pernicious anaemia occurring in a child
five years of age and running a very rapid course, without remissions,
until death occurred, only a month and a half after the inception of the
disease. The case is highly interesting as constituting, with one other,
the only certainly known instances of pernicious anaemia in childhood.
The whole account is sufficiently full and accurate, and, with the con-
firmatory evidence of the autopsy, leaves no doubt as to the correctness
of the diagnosis. /
The Relations of Scrofula and Tuberculosis. — Albrecht (Ibid.) in-
sists anew upon the pathological ^identity of tuberculosis and scrofula,
and, from recent literature, gives a host of instances where tubercle
bacilli have been found in scrofulous formations. The practical bear-
ing of the connection between these two rnorbid states is evident ; and,
if this connection were only a probable one, it would still claim our
attention in view of the great prevalence of scrofula and the fatality
of tuberculosis. If there is a chance that the former can develop into
the latter, or even if we are limited to the certainty that the former
leaves the system in a condition suitable for the development of the
latter, we must welcome any means by which scrofula itself can be pre-
vented, or by which, when once initiated, its further development can
be checked. According to Albrecht, we can effect the former by inocu-
lation of scrofulous material, conducted in the same way as a vaccina-
tion for small-pox. A further means for accomplishing the same end
is the refusal to permit a tuberculous mother to nurse her infant, and
a limitation, as far as possible, of the marriages of patients affected
with syphilis. For the suppression of scrofula when once inaugurated,
Albrecht recommends most earnestly the replacement of starchy by
nitrogenous diet, and more particularly the employment of peptones as
an aliment. Another very useful agent is the inhalation of oxygen.
This gas, given to children four or five years of age, in quantities of fif-
teen to thirty litres twice a day, notably stimulates tissue-metamorpho-
sis, and often renders possible a degree of super-alimentation which
could not otherwise be undertaken without endangering the integrity
of the organs of digestion.
The International Medical Congress. — In its last issue the "North
Carolina Medical Journal " says :
" Seldom has there been such unanimity of opinion upon any matter
164
MISCELLANY.
[N. Y. Med. Jouh.,
as we have seen expressed in the medical journals of this country on
the proposed International Medical Congress. We need not repeat in
detail the well-known story of the appointment of the original commit-
tee by the American Medical Association, with plenary powers to pre-
pare for the meeting of the Congress in 1887 ; of the opposition which
the printed provisional list of officers and members of the Congress met
with ; of the movement set on foot to reorganize the original commit-
tee, and thus give an opportunity for the admission of some of the mal-
contents to positions in the Congress ; of the reorganization of the offi-
cers and councilmen of sections in Chicago in such a way as to distrib-
ute the appointments over a larger area of the Union, not failing to
' punish ' (as they say in politics) original members who had condemned
the New Orleans movement, or were new-code men ; how some of the
active dissentionists were supplied with prominent places in the new
•organization ; how the leaders of the original committee were compelled
by self-respect to resign, and the most prominent members of the origi-
nal body in Baltimore, Philadelphia, and Boston promptly withdrew
their names, thus withdrawing from the Congress a considerable num-
ber of the ablest men in the country. It is a record painful to make,
not only because it means that the Congress can not now possibly be
what it could have been under the first organization, but because it
shows how large a share of medical politics can enter into the meetings
of such a loosely constructed body as the American Medical Associa-
tion when designing members choose to exert themselves.
" The ' Journal of the American Medical Association ' makes the
best it can of the situation, but is almost alone in the position it has
taken in defending the unfortunate reorganization. We agree with that
journal that the new appointments, with a few offensive exceptions,
have been judiciously made, but we believe that the whole movement
which culminated in the Chicago reorganization was discourteous to the
original committee, and that the ruling as to the legality of a body hav-
ing power to reorganize and reinstruct its committees has no bearing
upon a purely scientific body, composed of voluntary members, and
working without any other emolument than the reputation which would
ensue from eminent ability brought to the task.
"The sum of the unfortunate affair may be thus stated: We have
been made ridiculous in the eyes of the medical world. The proposed
Congress has been severely crippled. The American Medical Associa-
tion has given evidences of a state of things which must be corrected
or be ruined. The new-code men by this blunder have been advanced
to a position which no act of theirs could have accomplished for them
in a quarter of a century."
The "Maryland Medical Journal," in its issue of August 1st, says:
"Despite the very cheering assurances of the ' Journal of the Ameri-
can Medical Association ' that the Ninth International Medical Congress
will be conducted in the 'most liberal and enlightened manner' by the
* present able and judicious Committee of Arrangements,' the progress
of another week presents a wide-growing distrust of the recent work
of the committee at Chicago. The withdrawal of the appointees of the
committee in Philadelphia, Boston, Baltimore, and Washington has
been followed by similar resignations in Cincinnati, St. Louis, Chicago,
and in other localities. These declinations have come not only from the
gentlemen originally appointed by the first committee, but, in a number
of instances, the appointees of the present committee respectfully de-
cline to hold the honors awarded to them. Indeed, it seems to be quite
apparent that the gifts of this committee will go begging unless some
unseen power is raised up to prop its waning fortunes. Under exist-
ing circumstances it seems clearly the duty of this committee to aban-
don its work of reorganization as the most graceful and practical solu-
tion of the difficulties which embarrass it. By such a course the com-
mittee would in no sense lose the respect of the American profession.
It has been placed in a false position by the American Medical Associ-
ation. It has been called upon to perform a duty which no similar
committee of the association can perform under existing circumstances.
The present status of the Congress is the result of a false and unne-
cessary issue which can work no good to the American profession or to
the American Medical Association. Its introduction into this discussion
was totally unwarranted and unjustifiable. The ' code ' issue is not an
issue which should be raised in the organization of an International
Medical Congress. At previous meetings of the Congress all questions
of medical politics have been rigidly excluded, and such should have
been the case in the organization of the present Congress. The gentle-
men who have declined to hold positions under the present OOTOlpittW
of organization are 'old-code' men. Their action has not been influ-
enced by this question. Any attempt to impugn their motives on this
ground is an unjust and unwarranted assumption.
" The only point to be considered has been overlooked by the organ
of the association — in its great devotion to the interests of the present
committee of organization — while it vigorously assails the first commit-
tee and the gentlemen who decline to serve under the present commit-
tee. It is the fact that the Congress is a scientific body, that it is inter-
ested only in scientific work, that it should be organized only on a
strictly scientific basis, and that the gentlemen intrusted with the con-
duct of the Congress should be selected out of deference to this fact.
The composition of the Congress demanded that men should be selected
to its various offices irrespective of geographical position or 'code'
politics, but solely on the principle of natural selection — the best men
for the best positions.
" We do not deny the fact that the first committee made serious
blunders, that the doctrine of natural selection has been overlooked in
a number of instances. This fact did not, however, warrant the action
of the association in introducing false and absurd issues into the reor-
ganization of the Congress. The first committee performed a difficult
duty in a manner perhaps as satisfactory as any similar committee
would have done. It considered that it was constituted to organize a
body of scientific workers, and it was doing a duty to scientific medicine
when it lost sight of geographical lines and medical ethics.
" It is the grossest presumption on the part of the association
journal to charge these gentlemen with having used the association as
a ' decoy duck ' to obtain positions for themselves and for their friends,
and then 'coolly turn the association into a "foot-ball."' We must re-
gret the illogical and ill-tempered manner in which this ' journal ' dis-
cusses the points at issue in this controversy. It seems to us its posi-
tion is poorly taken, and its language is indiscreetly chosen. This
'journal' is now harping on the false issues introduced at New Orleans,
and it is no more representing the views of the majority of the mem-
bers of the association than the few malcontents, who captured the
New Orleans meeting, represented the true feelings of the membership
of that meeting. Our contemporary is in the position of the ox in the
mire. In its efforts to extricate the association from the serious blun-
ders it has made, it becomes more hopelessly entangled. It plunges
and charges in the mud of its own make, and hopelessly attempts to
fling this mud into the faces of gentlemen who are not responsible for
its unfortunate dilemma. It is a trite saying, ' Whom the gods wish to
destroy they first make mad.' This seems to be the unfortunate state
of mind which besets the leaders of the association and its official organ
at this time."
The " Canadian Practitioner " says : " We have watched with great
interest the progress that has been made in completing the arrange-
ments for the International Medical Congress, which is to be held in
Washington in 1887. As our readers well remember, the American
Medical Association appointed a committee, giving power to the same
to invite the medical world to America, and make the necessary arrange-
ments for the meeting. The invitation which was cordially given was
accepted in a very friendly spirit, and the committee proceeded with
the work it was asked to perform, and accomplished it most admirably,
as we thought. The officers and committees were chosen with great
care and prudence, truly representative men being placed in the most
important positions.
" We had supposed that the meeting of the American Medical As-
sociation recently assembled at New Orleans would gladly indorse the
acts of its committee, and say, Well done ! go on and complete the
work you have so well commenced. But no, says a narrow clique of
agitators, you have left certain States unrepresented, you have neglect-
ed the rural districts, and, worse than all, you have ignored a number
of us bumptious sore-heads, who are superlatively well qualified for
the most responsible positions iu the Congress. By some means, a ma-
jority of those present were induced to vote for a resolution which prac-
August 8, 1885.]
MISCELLANY.
165
tically censured the committee, and added enough new men to govern
the organization for the future.
" The new committee, including some members of the original com-
mittee, met at Chicago, June 24th, and made many changes in accord-
ance with the views expressed at New Orleans. Before these changes
' were confirmed, Dr. Billings explained the situation, from the stand-
point of the old committee, as follows :
" ' The invitation was purposely worded as coming from the medical
profession of the United States, and not from the association only, in
order that all regular physicians in the country, and in particular the
various important societies devoted to special branches, such as the
gynaecological, ophthalmological, laryngological, etc., and also the soci-
eties in our large cities which are specially devoted to scientific work,
such as the Academy of Medicine, of New York, the College of Physi-
cians, of Philadelphia, etc., should feel that they were included, and
must share the responsibility of providing a proper reception for the
Congress.'
"This broad view of the question was not acceptable to the commit-
tee. They had received orders to decapitate, and they decapitated ac-
cordingly. We have neither space nor inclination to discuss at length
the merits or demerits of the victims or their substitutes. While, in a
general way, we may say that the new appointments should, under ordi-
nary circumstances, be acceptable, this atfords no reason why equally
. good men should be subjected to such humiliation.
j " We can not help thinking that the method of procedure was, in
all respects, unmanly, ungenerous, and unjust ; and we sincerely sym-
pathize with that large portion of the respectable body of the profes-
sion in the United States who must feel keenly the humiliating position
in which they have been placed. Already this sad business is bearing
its bitter fruit. The respectable physicians of grand, conservative old
Philadelphia have, in a body, formally declined ' to hold any office what-
soever in connection with said Congress as now proposed to be organ-
ized.'
" We had looked forward to a very pleasant and successful meeting
at Washington. The ability, generosity, and hospitality of the physi-
cians and surgeons of the United States are well known to the whole
world. A few weeks ago the prospects for the proposed Congress were
exceedingly bright; now a dark cloud overhangs the undertaking, and
what the end will be no one can foresee. We would gladly welcome
any solution of the serious difficulties which would bring light out of
darkness, but, so far as we can see at present, the prospects are gloomy
in the extreme."
The "independent Practitioner," of New York, one of the ablest
of the journals that are devoted to dental surgery, says :
" In the last number of this journal it was announced that the re-
organized committee of the American Medical Association had dropped
the section of oral and dental surgery from the list of sections estab-
lished by the original committee. This action demands some notice on
the part of dental journals. At the London meeting of 1881 our sec-
tion played such an important part, it worked in such harmony with
the other sections, and contributed so largely to the distinguished suc-
cess of that Congress, that we had no reason to doubt that, here in
America, where dentistry has made such peculiarly rapid strides, where
as a branch of medical science it was first organized, where the modern
teaching of dentists as scientific men originated — here, among a people
who claimed pre-eminence in practical advancement, our specialty would
surely be given every opportunity to benefit by this convocation of all
that was great in medicine. In London there was no distinction be-
tween the various sections. In free democratic America it was antici-
pated that a section that would probably number more delegates than
any other would be given peculiar facilities. We are happy to say that
the Congress, as first organized by representative medical men, had ful-
filled all expectations. It remained for a rump association to outrage
respectable medicine by overturning that which had been established,
and to attempt to found a World's Congress upon sectional issues. It
shows a woful misconception of the character and purposes of the
Congress when local quarrels and questions of personal bias are injected
into the discussion thus early. They must indeed be men of narrow
views who would force a world's professional assembly to take sides on
a division of opinion among the physicians of the State of New York.
Will medicine as a whole never get above these petty squabbles '? Will
it never make good its boast of being a learned profession, and rise
superior to the pot-house wr angles which engage only minds of small
caliber ?
" That dentists may understand the present status, it is necessary
that we explain some things that may not be known to all of them.
The International Medical Congress is what its name indicates — a coun-
cil of the representative medical men of the world, which meets every
third year. It knows nothing of medical societies or medical polities,
but at each meeting accepts the invitation of the medical profession of
some country to hold its next session with them. It is never the guest
of any medical society, but it expects that the whole profession of the
country in which it meets will join in advancing its interests. It is not
intended to be a convocation of small men, nor is it anticipated that it
shall be so used as to advance individual interests. Especially does it
discourage all professional demagogism. In this country the American
Medical Association, as the nearest approach to a national organization
that we have, assumed to issue the invitations through a committee of
representative men, who, in the event of its acceptance, were directed
to complete an organization. This committee visited Copenhagen,
where the Congress of 1884 was held, extended the invitation, which
was accepted, and the committee thereby became an organizing com-
mittee of the Congress.
" They returned home and proceeded to complete their work by
adopting rules, establishing sections, and appointing their officers.
That this work was well done there can be no question. But upon the
reassembling of the American Medical Association in New Orleans, in
March last, in a place remote from the great medical centers, and where
the membership for the year would necessarily be made up largely of
those who were not conversant with the needs and feeling of the pro-
fession, it was found that a few determined demagogues, oily of tongue
and reckless of the best interests of the profession, had secured con-
trol of the association. They did not belong to the class of men who
have made medicine what it is. They were in no sense representatives
of the better part of medical science, and so they had not been ap-
pointed to commanding positions. But they were determined in some
way to make the Congress personally profitable to themselves, and they
accordingly headed a movement which resulted in the undoing of all
that had been done, and the appointment of a practically new commit-
tee, with themselves in the prominent positions.
" The plea under which this was done was, that the organization of
the Congress did not properly represent the country, and that some of
the new-code men of the State of New York had been appointed to
office. The speciousness of this claim will be seen when it is under-
stood that this is not a political assembly ; it is not the country which
is to be represented, but the profession of medicine, and such men
should be chosen as best typify the great profession, no matter if they
were all found in one city. If the backwoods of Arkansas could fur-
nish a man who could take rank with the leading minds of medicine,
he^ should be chosen. But, if not, Arkansas should wait until it could
produce such a man. As to the factional issue of new or old codes,
that was a matter with which the Congress had, and desired to have,
nothing whatever to do.
" But the new committee assumed the reins, and proceeded to re-
organize the Congress, displacing some of the men whose fame is world-
wide, and who cast a luster upon medical science, and putting in their
places some of the ambitious 'outs' who were great only in their own
conceit. They reduced the number of sections, dropping that of dental
and oral surgery, or, what is the same thing, consolidating it with gen-
eral surgery. The ' Medical Bulletin,' of Philadelphia, which is edited
by one of the leading spirits in the revolution, says : ' The omission of
the section of dental and oral surgery was judicious, dentistry not being
generally recognized as a legitimate department of medicine.' We may
well be content to rest under his ban, when he is at known issue with
very much that is reputable and honorable in medicine.
"Anticipating censure, the new committee fortified themselves with
the opinion of lawyers concerning the legality of their action. To what
end ? What have lawyers to do with the ethics of another profession ?
Did the committee propose to go to extreme legal limits, or was it their
desire to do what was professional and right ?
166
MISCELLANY.
[N. Y. Mud. Joub.,
"As might be imagined, their proceedings have excited a deep and
indignant feeling among the better part of physicians. The protests
have been many and vigorous. The most of the leading medical jour-
nals have forcibly denounced the movement. Meetings of leading medi-
cal men have been held in several of the large cities, and many of the
most respectable of the appointees have announced that they will have
nothing to do with the Congress as now organized. In Philadelphia,
such men as Agnew, Bartholow, Brinton, Da Costa, Gross, Hays, Leidy,
Mitchell, Stille, Tyson, Wood, and many others, with Yandell, of Louis-
ville, have formally withdrawn. The Philadelphia list of protestants
alone includes four presidents of sections.
" This action has been imitated in other cities, and so many eminent
names have been withdrawn that it now seems demonstrated that,
under the present organization, the Congress can not by any possibility
be made a success. The men now charged with the management of
the Congress are believed to be incompetent, and they certainly do not
possess the confidence of the profession, nor are they sufficiently repre-
sentative of the intelligence of those for whom they assume to act.
Therefore, as we said in the last number, it is probably as well that we
are not involved in the quarrel. The only thing that remains is to see
if the Congress can not be rescued from the hands of those who have
assumed its management. But even this could not probably be done
in time to re-reorganize with much hopes of making it what it should
have been.
"It is a shame and a scandal to medicine that such a state of affairs
can exist. But as long as such an organization as the American Medi-
cal Association, with its fluctuating, constantly changing membership,
shall be the representative Association of American Medicine, we have
little better to hope for. It is a complete political body, and, like all
such associations, it is usually controlled by demagogues and wire-pull-
ers. What medicine needs is a permanent body, that shall represent,
not its tricksters and politicians, but its intelligence, its professional
eminence, and its scientific attainments. This the American Associa-
tion does not and can not do, because its membership is founded upon
geographical, and not upon scientific or professional representation. It
now seeks to make the International Medical Congress but an enlarged
session of this unrepresentative body."
In the course of a spicy article entitled " The Late Proposed Medi-
cal Congress," the " Peoria Medical Monthly " says :
1 The Philadelphia protest and withdrawal contained twenty-eight
names, that from Boston nineteen, and Baltimore twelve, with more to
hear from. Twenty-seven from New York were ignominiously bounced,
and the list of officers and committees as it now stands is bereft of
such names as Loomis, Emmet, Bulkley, Keyes, Lefferts, Munde, Knapp,
Bosworth, Packard, Da Costa, Bartholow, Pepper, Mitchell, Gross, Hays,
Agnew, Parvin, Goodell, Leidy, Stille, Yandell, Williams, Blake, Chad-
wick, Chisolm, Johnston, Mackenzie, Lee, Tiffany, Theobald, Johnson,
Burnett, Prentiss, Baker, Huntington, Engelmann, etc.
" Poor Congress ! it looks as if it had ' died abornin',' or, at least,
was having an awful hard time to get started into this world (western
part of it) of sorrow and contention. The office of secretary-general
is vacant. The sections of therapeutics, medicine, anatomy, and sur-
gery are without heads, and other sections are partially dismantled.
And still the fight goes on."
The "New Orleans Medical and Surgical Journal" says:
"So, at the New Orleans meeting of the American Medical Associa-
tion, the report of the committee was presented and disapproved. Manv
of our readers will recall the intemperate discussion on the occasion.
It was characterized by offensive personalities, well calculated to widen
the differences already existing. One spokesman from the West, in
imitation of the wicked ruler who leveled the highest reeds in his gar-
den as a warning to his subjects, proposed to behead the great men of
the East. The sentiment was applauded. As a crowning act of dis-
courtesy to the original committee, composed of some of the most hon-
ored names on the roll of the association, a resolution was finally adopt-
ed appointing a new committee, to be composed of the membership of
the original committee of seven, enlarged by the addition of thirty-four
members of the association, one from each State and Territory repre
sented, and from the Army, Navy, Marine-Hospital Service, and the
District of Columbia. To the new committee, thus constituted, was
granted the power of reviewing, altering, and amending the work of
the original committee, as deemed necessary. This enlarged revisory
committee some of our most esteemed contemporaries choose to call
the ' New Orleans Committee.' True, the committee was born here,
but of foreign parentage, and certainly conceived elsewhere. It
is a fact worthy of record that not a single Louisianian raised his
voice in the discussion which led to the organization of the new com-
mittee.
" Already it is painfully evident that it is simply impossible to or-
ganize the American meeting of the International Medical Congress
upon the plan adopted by the Chicago committee. Truly, we stand to-
day a divided household, and, unless some reconciliation can be effected,
the failure of the Congress is inevitable. The present situation is de-
plorable beyond expression. A mighty responsibility rests on the pres-
ent Committee on Organization. The members must realize the impos-
sibility of organizing the Congress in further pursuance of the policy
recently adopted. For the sake of harmony, through which alone the
Congress can succeed, and the profession escape a national disgrace,
the committee should make concessions to the gentlemen who feel
aggrieved by their action ; and such concessions to those who have re-
signed, as well as those who have been displaced, should meet only
friendly responses and pledges of harmonious co-operation.
"We favor the organization of a National Committee of peace-
makers, composed of representatives from the States and Territories, to
be appointed by the presidents of State and Territorial societies ; from
the District of Columbia, to be appointed by the president of the Dis-
trict Society ; and from the Army, Navy, and Marine-Hospital Service,
to be appointed by the ranking medical officer of each service."
The "Canada Lancet" says:
" This action on the part of the leading members of the profession
seems a most serious step, but it arises from the fact that there is a
growing want of confidence in the ability of the American Medical
Association, as an organization, to carry out such an undertaking satis-
factorily, and also in the probable success of any Congress from which
the best known scientific men of the country are excluded. The action
of the committee in regard to the ' new-code ' men would indeed be
ludicrous were it not so serious, and will have the effect of creating
sympathy where before there was only cold and formal respect. The
insult offered to such veterans as Bowditch, Fordyce Barker, Draper,
Weir, Munde, Roosa, Knapp, Noyes, Agnew, Jacobi, and others, merely
because of a difference of opinion on the code question, will not be tol-
erated by the good sense of the American medical profession."
The "British Medical Journal" says:
" The most recent advices from the United States have brought the
startling intelligence that there exists in the American medical pro-
fession a very serious discord concerning the next International Medical
Congress. We do not propose to discuss the aetiology of this rupture,
for it is quite enough to be called upon to face the fact that it exists.
The fact is very grave. Its existence jeopardizes, if it have not already
destroyed, the probable success of the forthcoming Congress. Cer-
tainly our brethren in the States can not expect those who have already
promised to attend, and those who may expect to visit America at that
time, to work with enthusiasm in the preparation of any scientific con-
tributions while those whom they propose to visit are divided, and while
wholesale secessions of the official executive and of well-known persons
nominated to high offices are announced. Nor do we consider it to be
either our duty or privilege to suggest a remedy for this exceedingly
unpleasant dilemma. It seems to be conclusive that the profession in
America at this moment is hopelessly divided on the subject. Already
a large proportion of the influential and active scientific men of Phila-
delphia— such as Bartholow, Weir Mitchell, Da Costa, H. C. Wood,
Pepper, Leidy, Stille, Parvin, and Goodell, and David Yandell, of St.
Louis — have publicly withdrawn from the organization of the Congress.
A like number of distinguished men in New York — such as Loomis,
Roosa, Jacobi, Munde, Agnew, and Emmet — have also either resigned
or been dropped, and therefore will not co-operate with the present
organization. The outlook as the matter now stands is not at all en-
couraging. One committee has reorganized the work of another up to
the point near that of destruction. Moreover, the work of the present
August 8, 1885.]
committee must be submitted to the American Medical Association in
May, 1886 ; and no one can say to what extent it may also be either
overturned or modified in such a way as to seriously impede the labor
necessary to be performed before the meeting of the Congress in 188V.
Altogether, the position is lamentable, and there is much fear that the
acceptance of the invitation to meet in the States may be withdrawn,
and the next meeting of the International Medical Congress be held in
Berlin, or some other great medical center, pending the settlement of
the serious dissensions among our brethren of the United States."
Clinical Teaching in Obstetrics and Gynaecology. — It is pleasant to
note the constant increase of the facilities for the practical teaching of
these branches in New York. Besides the professors and instructors
at the Polyclinic and the Post-Graduate School, there are now several
very capable private instructors holding clinical appointments. We
would call attention to Dr. Garrigues's card, which appears in our ad-
vertising columns this week, and assure our readers that he will be
found most efficient as a teacher of obstetrics and gynaecology.
The University of Charkow. — The " St. Petersburger medicinische
Wochenschrift " states that Dr. J. Lasarewitsch, having served the ap.
pointed time as professor of obstetrics and gynaecology, has been made
a professor emeritus.
The University of Berlin. — We learn from the same journal that
Professor Gerhardt, of Greifswald, has been called to Berlin as an ordi-
nary professor in the medical faculty, and to succeed Professor Leyden
in the service at the Charite.
The Death of Professor Vogt, of Greifswald. — The same journal
announces that Dr. Paul Vogt, the Greifswald professor of surgery, died
suddenly, of heart disease, on the 5th of July, in the forty-second year
of his age. He had held the full professorship for only three years,
having succeeded Hiiter in 1882.
THERAPEUTICAL NOTES.
The Summer Diarrhoeas of Infants.— The "Medical Age," of De-
troit, contains, in its issue for July 25th, a valuable article on this sub-
ject, by its editor, Dr. J. J. Mulheron. He treats first of the causes of
these affections, dividing them into simple diarrhoea, entero-colitis, and
cholera infantum, and then speaks of the treatment as follows :
" The first thing necessary in undertaking the treatment of a case
of 'summer complaint' is to decide to which of the three forms of in-
testinal disturbance above referred to the case belongs, and, having
settled this point, to settle on some definite theory of its nature and
the pathological conditions which obtain. Without these preliminaries
the physician must flounder aimlessly about.
" The armamentarium which I would suggest in going out to cope
with the summer diarrhoeas of infants comprises the following drugs
and remedies, it being understood, of course, that the dietary shall be
determined pro re nata. The drugs are mentioned at random, and are
not given in the order of their importance : Castor-oil, prepared chalk,
calomel, creasote, salicylic acid, opium, strychnine, vegetable astrin-
gents, ergot, belladonna, chamomile, bromide of potassium, sulphuric
acid, subnitrate of bismuth, oxide of zinc, cocaine, the spice poultice,
and warm and cold baths.
" A brief review of the physiological action of these may assist to
their therapeutic application. Castor-oil is a mild but decided purga-
tive, and is at the same time an emollient through its action on the in-
testinal mucous membrane. Prepared chalk (carbonate of calcium) is
an antacid. The belief that calomel is a cholagogue is now very gen-
erally discarded. The drug has, doubtless, a complex action, but for
our present purpose it is sufficient to state that it is an antiseptic, hav-
ing specially marked anti-fermentative properties. Experiments con-
ducted by Wassilief in Hoppe-Seyler's laboratory are quite conclusive
as to its influence in preventing decomposition and butyric-acid fermen-
tation in the intestines. Added to a cultivating fluid, it prevents the
development of micro-organisms, while it destroys the activity of those
which have already formed. These properties are, probably, due to the
formation of the bichloride of mercury through its union with the chlo-
167
rides of the stomach. Creasote is intensely poisonous to all forms of
infusoria and fungi. It allays irritative conditions of the gastric nerves
and becomes thus also an excellent anti-emetic. Salicylic acid destroys
low forms of organic life and ferments. Opium has a very manifold
action, but for our present purpose it is sufficient to recall the fact that
it is an anodyne, that it diminishes peristaltic action of the bowels, and
that it checks secretion from all surfaces except that of the skin.
Strychnine, besides its characteristic action on the spinal motor nerve-
centers, influences also such portions of the cord as affect the vaso-
motor centers. Without being able to state its exact physiological
action in this direction, clinical experience has demonstrated its value
as a tonic in atony and relaxation, both of striated and non-striated
muscular tissue.
" Ergot has the peculiar property of causing vaso-motor spasm, and
its action is noticeable in the non-striated muscular fiber of the intes-
tines as in the same tissue found elsewhere. Belladonna is a stimulant
to the vaso-motor centers, causing contraction of the capillaries. It
checks secretion from glands. It relieves pain, Anstie regarding it as
the best remedy to mitigate pain of every kind in the pelvic viscera.
Chamomile, through the volatile oil which it contains, possesses the
power of subduing reflex excitability. Grisan found it impossible to
tetanize with strychnine a frog which had been fortified with chamo-
mile, and, vice versa, when excitability had been produced by strych-
nine it could be calmed by means of chamomile oil. The power of
bromide of potassium in allaying reflex excitability is well known.
Subnitrate of bismuth acts, probably, locally, forming a coating over
the mucous membrane and protecting it from the action of irritants.
Oxide of zinc, besides being an astringent, possesses also the property
of allaying reflex irritation. Sulphuric acid is tonic and astringent,
with an apparently specific action on the intestines. The local anaes-
thetic action of cocaine has been so much discussed recently as to make
reference to it unnecessary. It suggests itself as an application to the
irritated gums. The spice poultice is a counter-irritant, and is, proba-
bly, also antispasmodic through absorption of the oils which it con-
tains.
" Simple Diarrhoea. — Assist the effort of nature to rid the bowel
of irritant matter with a dose of castor-oil. Follow this by sufficient
doses of prepared chalk to correct the acidity of the discharges, give
opium to diminish the peristaltic action, and give astringents and
strychnine to restore tonicity. The following is a good formula for a
child of, say, eighteen months :
Tr. opii camph § ss. ;
Ext. rubus villos. fl ^ j ;
Tr. nucis vomicae gtt. xij ;
Mist, cretae q. s. ad § iij.
M. Sig. A teaspoonful every three hours.
" Entero-Colitis. — When the character of the stools, the elevation
of the temperature, the disturbance of the stomach, etc., indicate the
involvement of the intestine in a catarrhal inflammation, the means em-
ployed in the simple diarrhoea, which is usually the precursor of these
graver symptoms, must be supplemented by other remedies. Place
the child on small doses of calomel and ipecac — say a twelfth of a grain
of each for a child of eighteen months — every two hours, alternated
with a teaspoonful of an infusion of five chamomile flowers in a cup
of boiling water. The spice poultice, moistened with hot brandy, must
be laid over the abdomen. If the temperature pass 101° F., it must
be reduced by baths, the water of which must at first be tepid, and
gradually cooled to 70° F., or lower, as the circumstances of the case
require. Should twenty-four or thirty-six hours of this treatment be
followed by no betterment, and the stools continuing or becoming more
colliquative, I have found the following formula to answer admirably,
quieting the irritability of both the stomach and the bowels :
Creasoti gtt. iv ;
Zinci oxidi gr. xvj ;
Tr. belladonna; 3 ss. :
Glycerini 3 ss. ;
Aquam q. s. ad * ij.
MISCELLANY.
168
MISCELLANY.
[N. Y. Mud. JorjK.,
M. For a child a year old : Sig. A teaspoonful every three
hours. This may be alternated with aromatic sulphuric acid, two drops
in ten drops of brandy, every three hours. The spice poultice should
be continued.
" Cholera Infantum. — Bearing in mind our conception of this affec-
tion as a neurosis, our treatment should be directed, ' first, to destroy-
ing the organisms, on which every fermentation depends for its devel-
opment ; secondly, to allaying the irritation of the end organs of the
splanchnics in the mucous membrane ; thirdly, to arresting the outward
osmosis from the vessels ; fourthly, to lowering the febrile temperature
and removing the algid condition.' My experience leads me to speak
with favor of salicylic acid and chalk, as recommended by Dr. Hutchins
in the September, 1880, number of the ' Proceedings of the Medical
Society of the County of Kings,' N. Y., as a remedy meeting the first
and second of these indications. This combination is useful only in
cases of serous diarrhoea, having no efficacy in the inflammatory or
lienteric form. It acts happily, also, in allaying gastric irritability.
Three grains of salicylic acid, rubbed up with two grains of prepared
chalk, should be given every three hours. Care should be taken that
the chalk be pure, and that, during the effervescence attending the
addition of water to the powder, no odor of chlorine be emitted. Such
odor denotes the presence of chlorine — a residuum of the manufac-
ture of chlorinated soda. It is apt to exist in prepared chalk, and
should be carefully avoided. The creasote formula, given above, for
entero-colitis, has also answered a good purpose, especially in cases at-
tended with much gastric irritability.
" There are few cases of cholera infantum in which the bromide
of potassium will not prove helpful, and especially when there ex-
ist restlessness, wakefulness, and twitching of the muscles. It allays
the irritation of the splanchnics, and of the nervous system gener-
ally.
" Baths hold an important place in the treatment of the fever of
cholera infantum, and for one reason, among others, that it is of little
use to administer medicines as long as the temperature is elevated.
The soothing influence of a cold bath on a child whose temperature has
reached, say, 103° F., and the increased activity of the drugs adminis-
tered after the bath, need but to be witnessed to make converts to this
much neglected remedy in the treatment of cholera infantum. The
child should be immersed up to its neck in water at a temperature of
95° F., to which cold water should be added until the bath reaches 70°,
or even lower, the condition of the patient, his temperature, etc., being
the guide to the reduction. No hard-and-fast rules can be laid down
to govern the temperature of the bath or its frequency. The condition
of the infant must be the guide, which the good sense of the physician
must be trusted to interpret and follow.
" When the child has entered the algid stage of the disease, treat-
ment offers little hope of rescue. Alcoholic stimulants and warm baths
are about the best we can apply. Belladonna, through its action on the
heart, suggests itself as a remedy in this condition, and experience has
shown it to be of value. By paralyzing the terminal inhibitory fila-
ments of the pneumogastric, it gives the heart over to the sympathetic,
and we have, as a consequence, increased rapidity of contraction and
raised arterial tension — a condition of affairs which it would seem very
desirable to secure in the cold stage."
Osmic Acid in the Treatment of Neuralgia. — Schapiro (" St. Pe-
tersb. med. Woch.") summarizes the results met with by a number of
observers in the use of injections of osmic acid for the relief of various
forms of neuralgia, and gives the details of his own experience, which
relates to eight cases: 1. A woman, thirty-eight years old, was cured
of a neuralgia of the second and third branches of the right trigemi-
nus by twelve injections. 2. A woman, fifty-two years old, was cured
of a neuralgia of the same branches by twenty injections. 3. A woman,
thirty-eight years old, with neuralgia of the first and second branches
of the left trigeminus, was improved by ten injections. 4. A woman,
thirty-six years old, was cured of a neuralgia of the second and third
branches of the right trigeminus by one injection. 5. In the case of a
woman, thirty-three years old, with neuralgia of the occipital nerve and
both trigemini, one injection seemed to increase the severity of a mod-
erate paroxysm, and she declined the further use of the remedy. 6. A
man, sixty years old, with neuralgia of the second and third branches,
of the right trigeminus, was improved by twelve injections. 7. A man
sixty years old, was cured of a neuralgia of the first and third branches
of the right trigeminus by eight injections. 8. A man, fifty-three years
old, was cured of a neuralgia of the second and third branches of the
right trigeminus by six injections. Momentary faintness followed an
injection in one instance, but he states that, with that exception, he
has observed no unfavorable effects.
The Use of Ergot during Labor.— Saxinger, of Tubingen (" Dtsch.
med. Wchnschr." ; " Ctrlbl. f. Gyn."), defends the use of ergot dur ing
the expulsive stage of labor, provided the head is low in the pelvis,
and even in cases of contracted pelvis, after the head has become fully
molded. He quotes Schatz to the effect that ordinary doses simply in-
crease the frequency of the uterine contractions, without making the
individual pains stronger. At Seyfert's clinic, for the past three years,
he has observed excellent results from the use of an extract recom-
mended by Dr. Denzel, which is said to contain none of the active prin-
ciples but sclerotinic acid, ergotin, and ecboline. Rather more than
a grain and a half of this extract may be considered the equivalent
of fifteen grains of powdered ergot. The author thinks that the
use of ergot during labor will be recognized as legitimate so soon as
a preparation free from deleterious constituents becomes generally
available.
Salicylic Acid in the Treatment of Chancroid. — Notta (" Union
med.") gives the following formulae :
Salicylic acid 1 part ;
Flour, i
Powdered gum arabic, f 2 Parts-
Mix.
Salicylic acid 3 parts ;
Oxide of zinc, i
Powdered starch, Jeach 15
Vaseline 20 "
This ointment is used by Mauriac at the Hopital du Midi.
The Treatment of Pyrosis. — A contributor to the same journal"
gives the following formula, on the authority of Peter :
Powdered bicarbonate of sodium 37 grains ;
Prepared chalk 15 "
Extract of nux vomica 1£ grain.
Mix and divide into ten powders, one to be taken three times a day.
They are prescribed for persons with whom a milk diet disagrees, but
for whom that diet is ordered. If diarrhoea occurs, subnitrate of bis--
muth is given, in doses of seven or eight grains, with a sixth of a grain
of extract of nux vomica, and from a sixth to a third of a grain of pow-
dered opium.
The Treatment of Whooping-cough. — The same writer (Ibid. ) at-
tributes to Roger the following method of treating prolonged and severe
whooping-cough (" hypercoqueluche chronique"):
Ammoniac 1£ to 7£ grains ;
Syrup of orange-flowers or of red poppy. 375 "
Infusion of elecampane or of Virginia
snakeroot 1,125 "
Dose, a teaspoonful, to be repeated with greater or lesser frequency)
according to the child's age and the effect produced. When the expec"
toration is very abundant and as if formed of muco-pus, a terebinthi-
nate (syrup of fir-cones, of eucalyptus, or of turpentine) is prescribed-
Flowers of sulphur, mixed with honey (from three quarters of a grain
to two grains or more of sulphur), may also be given twice a day. It is
well, too, to rub the chest or the sides of the neck with a soothing
ointment, such as one containing a drachm of the extract of aconite or
of conium to half an ounce of lard.
Menthol as a Local Anaesthetic. — Rosenberg (" Berl. klin. Wchn-
schr." ; " Lancet ") finds that a twenty- or thirty-per-cent. solution of
menthol, which is much cheaper than cocaine, is a useful substitute for
the latter as an anaesthetic application to mucous surfaces, like those
of the nose, the pharynx, and the larynx. Although its effect is more
evanescent than that of cocaine, it appears to be somewhat cumulative,
for, when repeated, even after a long interval, the later application pro-
duced a longer period of anaesthesia than the earlier one.
THE NEW YORK MEDICAL JOURNAL, August 15, 1885.
(Original Cflmmimiottions.
OBSERVATIONS ON THE MEDICAL AND
SURGICAL TREATMENT OF ACUTE
PERITONITIS*
By T. HERRING BURCHARD, A.M., M. D.,
LECTURER ON SURGICAL EMERGENCIES, BELLEVUE HOSPITAL MEDICAL COL-
LEGE ; ATTENDING SURGEON, CHARITY HOSPITAL, ETC.
Peritonitis may well be regarded as the most fatal of
the acute inflammatory diseases-. After a careful compila-
tion of various hospital statistics, etc., I think its mortality
may be set down, when all varieties of the disease are con-
sidered, at about from fifty to sixty per cent,, and from
twenty to thirty per cent, higber when so-called ''idiopathic
cases " are excluded. Indeed, as is well known, there are
certain cases, especially such as are incident to septic poison-
ing, and others that follow perforation of the bowel, in
which a fatal termination may be said to be inevitable.
Believing that this mortality is unnecessarily high, and
that certain patients with peritonitis are permitted to die who,
perchance, under different procedures might be saved, it is
my desire to formulate and emphasize certain principles of
treatment already known, although not as yet generally ac-
cepted by the profession.
All treatment, to rise above mere empiricism, must rest
upon a threefold conception — a conception of the cause of
the disease, a conception of the natural history of the dis-
ease, and, finally, the natural tendencies of the disease, or
a foreknowledge of the mode of recovery or death. These
principles apply with special pertinency to the treatment of
peritonitis, and, before we can expect to treat that disease
I rationally, we must first know what causes it, and then how
it kills.
Without going into unnecessary detail, it will suffice to
know that peritonitis may originate from external trauma-
tisms, from internal traumatisms, by extension of inflam-
mation from contiguous parts, from septic causes and cer-
tain blood diseases (as rheumatism, Bright's disease, etc.),
and possibly, though rarely, from causes that are purely
miasmatic and climatic, constituting the so-called idiopathic
; cases.
Now, what are the causes of death ?
According to the text-books, collapse and asthenia. Ac-
cording to clinical and pathological observation :
1. Collapse, which represents the shock received by the
nervous system from injury inflicted on the largest serous
j membrane of the body.
• 2. Asthenia, which may be more intelligently expressed
by, a, heart failure ; b, respiratory failure.
3. By inflammatory changes in the lungs.
4. By inflammatory changes in the kidneys.
5. By hyperpyrexia, as a special cause, superinducing any
or all of the foregoing.
Any treatment, to be successful, must be prosecuted in
* Read before the New York Academy of Medicine, May 21, 1885.
the light of these clinical facts, and, in this understanding,
the following considerations are submitted :
1. The rarity of idiopathic peritonitis being now gener-
ally admitted, it is of paramount importance that each case
should have its aetiology definitely determined at as early a*
period as possible.
The mere fact that peritonitis exists is not sufficient in
itself to justify the adoption of any course of treatment.
This primary diagnosis, like the sign-board by the wayside,
simply points the way to further explorations.
So long as peritonitis is regarded as a finality rather
than as the expression or symptom of some organic dis-
turbance, but little help can be expected from other than a
purely empiric line of treatment.
The views of the profession have undergone a great
change in this respect. As Dr. Savage tersely puts it
("Brit, Med. Jour.," January 31, 1885), "We are learning,
if we have not already learned, to look on peritonitis as a
symptom of some organic change, and not as a disease in
itself. And this is well for our patients, because operative
measures can do much for it. We shall, ere long, regard
so-called ' idiopathic peritonitis ' almost as a curiosity."
In no other disease is an early knowledge of the causa-
tion of the attack so essential, and yet how often is the
etiological factor totally ignored in our haste to adopt a
course of treatment which, while it mitigates symptoms and
apparently gives relief, at the same time unwarily leads us
on to a fatal though, perchance, a painless finale !
It is in the incipiency of the attack, before excessive
tympanites has disturbed the normal configurations of the
abdomen and fatal asthenia has developed, that the golden
opportunity for successful diagnosis exists.
One word as to the alleged difficulties of accurate diag-
nosis under such circumstances. So much has been said
on this subject that they have come to be regarded as well-
nigh insuperable. Yet, under a systematically conducted
examination, which necessitates the interrogation of each ab-
dominal viscus and which seeks to find a satisfactory explana-
tion for each abnormal symptom, it is surprising how the
difficulties will dissipate. It is owing to a want of thorough-
ness in the examination and a lack of the judicial element
in weighing symptoms, rather than to inherent difficulties
often, that the diagnosis seems so obscure. Six times have
we seen fatal peritonitis develop after acute perforation of
the vermiform appendix, and in five cases out of the six has
the autopsy verified the diagnosis. (" N. Y. Med. Jour.,"
January, 1881.)
Of nine cases of intestinal obstruction that have fallen
under our personal observation, two cases have recovered
without surgical interference; hence the diagnosis could not
be verified. Of the remaining seven, a positive diagnosis
was made in five. In three of these I did laparotomy —
twice with success. The autopsy revealed the correctness
of diagnosis in the two remaining cases. (See " Transac-
tions of N. Y. Co. Med. Soc," meeting of April 7, 1884, p.
296.)
These diagnoses were made and the local lesion differ-
entiated under conditions of collapse, tympanitic distension,
170
BURGH ARB: THE TREATMENT OF ACT TE PERITONITIS. ' |N. Y. Mkj>. Joint,]
and abdominal pain, for these are the prominent symptoms
ushering in acute peritonitis, and are cited in this connec-
tion to show that a diagnosis which is practically accurate
is feasible. (For fuller information regarding diagnosis the
.reader is referred to an article by the author on " Operative
Interference in Acute Perforative Typhlitis," " N. V. Med.
Jour.," January, 1881.)
2. The diagnosis being made, and a local lesion amena-
ble to surgical interference being demonstrated, surgical
relief should be rendered at the earliest moment practicable.
The peritonaeum behaves very differently under different
'circumstances. It seems scarcely credible that the same
structure that will passively submit to the enormous disten-
sion of a gravid uterus or an ovarian cyst would reject so
summarily the trifling local irritation consequent upon some
minute intestinal perforation. Yet such is its behavior
under acute irritations that the rule might well be formu-
lated that all foreign substances, solid, liquid, or gaseous,
of an irritating nature, when introduced into the peritoneal
cavity, will inevitably and rapidly produce acute inflamma-
tion. The history of such traumatisms is, as we have
shown, most unfortunate, the terrible features of the attack
precipitating themselves with a rapidity and malevolence
that are simply appalling.
What, under the circumstances, are the indications for
treatment? Were the irritation located elsewhere in the
body than in this much-dreaded locality, sound surgical
judgment would advise the immediate removal of the irri-
tant. Why, then, should the peritonaeum, a structure which
is daily proving its immunity to surgical manipulation by
giving to surgery its brightest triumphs, not be subjected
to the same wise principles that guide us elsewhere in our
operative procedures?
True, it is no trifling responsibility we assume when we
propose, in the very face of a commencing peritonitis, to
open the cavity of the abdomen, release a strangulated
bowel, divide constricting bands, or cleanse the cavity from
purulent extravasations. But, in view of the exigencies of
the situation and the absolute imminence of death, do we
shift these responsibilities one iota when we sit supinely by,
knowing full well the inevitable fatality that attends the
orthodox methods of treatment? What ovariotomist is
there that would hesitate a moment to remove stitches and
reopen a wound in case internal bleeding or purulent accu-
mulations demanded it? Too well does he know the fatal-
ity of temporizing. How many more valuable lives, then,
are yet to be sacrificed before the profession realizes the
necessity of surgical interference in these desperate cases
of internal abdominal traumatism ?
Marion Sims ("Brit, Med. Jour.," December 17, 1881)
in this very hall sounded the key-note of the future treat-
ment of such cases when he said : " Given a case of perfora-
tion of intestine, and given an accurate diagnosis, which is
by no means difficult, what are we to do in the present
state of our knowledge ? Why, of course, we should open
the abdomen promptly, clean out the peritoneal cavity,
search for the perforation, pare its edges and bring them
together with sutures, and treat the case as we now treat
other cases involving the peritonaeum. Rest assured," he
says, "that the day will come, and it is not far off, when an
accurate diagnosis in such cases, followed by prompt action,
will save life that must otherwise quickly ebb away."
Dr. Robert W. Johnson, chairman of the Surgical Sec-
tion of the Medical and Chirurgical Faculty of Maryland,
said in his Annual Report (N. Y. " Med. Record," p. 550) :
"The greatest triumphs of the year (1884) are in abdomi-
nal surgery, Dr. Bull's case of laparotomy and sut ure of the
intestine for gunshot wound being the greatest of them
all." lie then goes on to state : " The abdomen should be
opened in case of perforation of intestine, hemorrhage,
extravasation of fa-ces, and br<Tninnt<j peritonitis, just as in
cases where internal strangulation has been positively diag-
nosticated, but only under full and complete Listerism, (1)
because without operation the patient is almost sure to die;
(2) the danger is far more than counterbalanced by the
chances of recovery."
To familiarize myself with the technique of the opera-
tion, three times I have laparotomized dogs, resected one or
more segments of intestine, suturing with catgut the divided
gut, and, notwithstanding the difficulty of keeping the ani-
mals quiet, they all recovered. Twice I have subcutaneous-
ly perforated with a slender bistoury the gut of a dog, and,
after forcibly squeezing some of the intestinal contents and
blood into the peritoneal cavity, have opened the animals,
washed out the abdomen, sutured the perforations, and had
one of the dogs recover.
The point raised by Dr. James R. Wood in the discus-
sion on Dr. Sims' s paper, to which reference has already been
made — namely, that " pathological surgery or operations done
for tumors and disease were very different in their results
from traumatic or acute surgery, and that this was specially
true regarding manipulations of a large serous membrane
that resents all impertinent interference " — does not, it
seems to me, afford a sufficiently logical basis for doing or
not doing the operation.
As a clinical fact, the peritonaeum is exceedingly toler-
ant of interference, provided the proper precautions are
observed.
Note the vast number of Tait's operations alone that
have been done during the last three years, and the splen-
did results that have been obtained. Death in these cases
has resulted from peritonitis but rarely. More frequently
it has been from septicaemia or shock.
In order to show the tolerance of the peritonaeum under
operations done for the relief of acute irritations, as well as
to emphasize the principle I maintain, I beg to present in
evidence the following cases, purposely omitting all cases
of hernia or intestinal obstruction, referring the reader to
Mr. Treves' s recent excellent work on the latter subject :
Case I. Kuester ("Verb. d. deutsch. Gesellsch. fur Chirurg.,"
viii, 1879). — Rupture of the sac of an incarcerated crural hernia
with escape of faeces into the peritoneal cavity during a kel-
otomy. Immediate laparotomy and resection of the gut. Death
from septic peritonitis.
Case II. Scheide (" Verb. d. deutsch. Gesellsch. fur Chirurg.,"
1878). — Laparotomy in a case of incarcerated umbilical hernia
with gangrene of the gut.
Death four days after operation.
August 15, 1885.]
BURCHARD: THE TREATMENT OF ACUTE PERITONITIS.
171
Case III. Schetelig ("Berl. kl. Wochenschr.," xvii, 80, 607).
— Knife wound of the abdominal wall in a decrepit man of six-
ty. Protrusion and laceration of a part of the colon. Reposi-
tion impossible at first. Enlargement of the upper part of the
wound with subsequent replacement of the bowel. Recovery.
Case IV. Wittelshoefer ("Wien. med. Wochenschr.," xxxi,
81, 118). — Man brought to Bamberger's clinic with the follow-
ing history: Some days before he had introduced a painter's
brush into the rectum to stop a diarrhoea, but when he tried to
take it out it had disappeared. On admittance, presents signs of
peritonitis, and examination shows the presence of the body in
the sigmoid flexure. Other means proving of no avail, he is
transferred, three days after, to Billroth's clinic for operation.
Patient at this time gives symptoms of severe peritonitis and is
somewhat collapsed.
Operation by Billroth. — Laparotomy. Incision beginning
at anterior superior iliac spine and extending as far as the sym-
physis. Peritoneal cavity is found filled with faecal matter, in-
dicative of a perforation. Brush found in the ascending colon
and removed by an incision 7 ctm. in length.
Toilet of peritonaeum, wound of gut sutured, severe collapse
after operation. Death.
Autopsy shows perforation of the peritoneal covering of the
gut 25 ctm. above the anus.
Case V. Wittelshoefer ("Wien. med. Wochenschr.," 1881,
xxi, 118). — Man, aged fifty-two, brought to Bamberger's clinic,
November 8th, with obstinate constipation of six days' duration.
On admittance, presents already signs of peritonitis, stercorace-
ous vomiting, etc. He is found to have a small umbilical hernia,
reducible.
Transferred to Billroth's clinic November 18th. At that time
already in collapse. The hernia is not so easily reduced, and is
somewhat painful.
Laparotomy. Incision in linea alba 18 ctm. iD length. On
opening the peritoneal cavity, a quantity of foetid matter oozes
1 out, and there are signs of a general peritonitis. Examination
j shows gangrene of the gut a little above the ileo-caecal junction,
and volvulus. Resection. Death in collapse five hours after
operation.
Case VI. Assmuth (" St. Petersb. med. Wochenschr.," 1881,
vi, 118). — Incarcerated umbilical hernia in a man aged forty-
! five. Symptoms of acute ileus.
Laparotomy . Omentum and gut found gangrenous and ex-
cised. Sutured. Recovery.
Case VII. Weinlechner (" Jahrb. fiir Kinderh.," 1881, xvii,
304). — Laparotomy in a child five years old, with intussusception
after the development ot acute purulent peritonitis. Resection
of intus3uscepted part.
Death five hours after operation from exhaustion.
Case VIII. Hoffmann (•' Wien. med. Presse," 1881, xxii, 114).
— Man aged twenty-four brought to Bamberger with acute gas-
| trie symptoms. Diagnosis: perforating gastric ulcer. Trans-
ferred to Billroth. Laparotomy performed and showrs a perfo-
rating ulcer on upper curvature. Edges are excised and united
by sutures. Death day after operation.
Autopsy shows an enormously distended stomach with thick-
; ened walls. What had been taken for an ulcer was probably a
spontaneous rupture, the result of the extreme distension.
Case IX.— Hagens (" Berlin, kl. Woch.," 1883, xx, 106).—
, Historical account of one of the oldest cases of gastrotomy, 1635.
Operation performed by Schwab on a peasant who had swal-
i lowed a knife. Incision two fingers' breadth under the free
> border of the ribs. Wound in stomach united by sutures; ab-
dominal wound closed. Recovery.
Case X. Maurer. — Perityphlitis in a man aged seventeen.
Incision extending from the quadratus lumborum muscle ante-
riorly to the anterior iliac spine. Opens into an abscess cavity,
communicating with the perforated colon. Recovery.
Case XI. Weinlechner ("Wien. med. Blat.," 1882. "Ileus
in a Man Aged Fifty-two," No. 44). — Laparotomy; incision in
median line. Death from peritonitis eighteen hours after. Au-
topsy shows perforation of appendix vermiformis and perityph-
litis.
Case XII. A. Schmidt (•' Wratsch.," 1881, No. 51, and " Cen-
tralbl. fiir Chirurg.," 1882, No. 47). — Slow purulent peritonitis
in a man aged twenty-one. By aspiration, a thin purulent fluid
is obtained. Laparotomy. Incision extending from the navel
to the symphysis. The whole peritoneal cavity filled with pus;
about five pounds. Removed. Drainage, etc. Complete re-
covery.
Case XIII. Gussenbauer ("Wien. med. Blat.," 51, 52).—
Sword-swallower, aged nineteen, during one of his perform-
ances breaks the blade in the oesophagus. The lower frag-
ment is pushed into the stomach by the father, as the boy seems
to be choking. On admittance, an examination is at once made,
but fails to detect the body either in the oesophagus or stomach.
Peritonitis developing, gastrotomy is performed, with extraction
of the fragment, which is 27 ctm. long. As no perforation can
be detected, closure of the gastric and abdominal wound.
Death. Autopsy shows septic peritonitis, wound of the
oesophagus 14 ctm. above the cardia, and a perforation at the
fundus of the stomach.
Case XIV. Kocher (" Corresp.-Bl. f. schweiz. Aerzt," Nos.
23, 24). — Gunshot wound of the stomach, in a boy of fourteen,
quickly followed by peritonitis and collapse. Laparotomy three
hours after. Wound of stomach closed by catgut sutures (Lem-
bert's) ; closure of abdominal wound. Recovery. Patient out
of bed seventeen days after.
Case XV. Sonnenburg ("Berl. kl. Wochenschr.," 142,
1885). — Rupture of the bladder in a man aged thirty-six years.
Laparotomy after the establishment of acute symptoms. Ab-
dominal cavity is found filled with urine mixed with fibrino-
serous fluid, and signs of peritonitis. The rupture is situated at
the inner side of the bladder. It is found impossible either to
unite the ruptured part or to sew the bladder to the abdominal
wall. Drainage of abdominal cavity. Death eight days after
from infiltration of urine and septicaemia.
Mikulicz (" Tageblatt d. Versamml. deutsch. Naturforsch. und
Aerzte," Magdeb., 1884, 1, viii, 224). — Mikulicz performs lapa-
rotomy in all cases of injury, whether direct or indirect, to the
stomach and intestines, even where peritonitis is already pres-
ent. He cites the four following cases:
Case XVI. — Laparotomy for rupture of the stomach in a
man aged twenty-four. Perforation found at the leaser curva-
ture, and is probably the result of extreme dilatation of the
stomach. Abdominal cavity is full of fragments of partly di-
gested food. Death three hours after operation.
Case XVII. — Symptoms of obstruction and ileus following
a diarrhoea (three weeks' duration) in a young man. Diagnosis:
strangulation of the gut. Laparotomy is performed, and about
one litre of fibrino-serous matter is removed from the abdominal
cavity. Volvulus present and reduced. Recovery from opera-
tion, but death three weeks after from intercurrent pneumonia. \
Case XVIII. — Perityphlitis followed soon after by symp-
toms of incarceration. Laparotomy (incision in linea alba).
Two litres of foetid purulent matter are removed from the ab-
dominal cavity. Death five days after. Autopsy shows a per-
oration of the intestine.
Case XIX. — Acute signs of ileus and incarceration in a
young man. Laparotomy, One litre of foetid pus and a num-
ber of pieces of undigested potato found in the abdominal cav-
ity. A perforation is also discovered, on the left side, involv-
172
BURCHARD: THE TREATMENT OF ACUTE PERITONITIS. [N. Y. Mko. JocB.,
ing the ileum, about G mm. long and 4 mm. broad. No cause
can be found for the perforation except that it is a typhoid ulcer
in a case of typhoides ambulatoria. Edges of perforation united
by sutures. Rapid recovery.
Case XX. Brugisser (" Corresp.-Bl. f. schweiz. Aerzt "). —
Acute signs of ileus strangulation and peritonitis in a man of
seventy-four. Laparotomy ; incision parallel with Poupart's
ligament. Resection of strangulated bowel. Recovery.
Case XXI. Lloyd ("Brit. Med. Jour.," Marcb 24, 1883).—
M. L., a domestic, aged nineteen, was admitted to Woman's
Hospital late in the evening of February 23d. She had been
accidentally shot in the abdomen three hours previously. No
shock and but little vomiting. Bullet had entered slightly to
the left of the median line immediately above pubes. Finger
passed readily into peritoneal cavity. Patient becomes steadily-
worse, and on the 20th has constant vomiting, severe abdominal
pain, a temperature of 99°, and a thready pulse. Laparotomy
in the evening ; abdominal section at once followed by escape of
a foetid, thick, brownish fluid. The intestines are matted to-
gether. A coil of gut, hooked from the left iliac region, has in
it a ragged wound three quarters of an inch in diameter. Ab-
dominal cavity washed out with plain lukewarm water, a glass
drainage-tube inserted, and perforated gut stitched to the cen-
ter of the abdominal wound. Patient never rallies, and dies in
collapse one half hour after. Autopsy shows that bullet has
contused the apex of the bladder, cut through the free edge of
a coil of intestine, perforated the mesentery and lies between it
and the mesocolon.
Case XXIL— Savage ("Brit. Med. Jour.,1' April 14, 1882)
reports seventy cases of abdominal section performed that year.
Six laparotomies during presence of subacute peritonitis with
more or less exudation. All the patients recovered.
Case XXIII. Bouilly (" Bullet, de la soc. de chir.," 8 aout).—
In a man, aged twenty-nine, who has received two hoof blows
in the umbilical region, Bouilly performs laparotomy twenty-
three hours alter the injury, as symptoms of perforation and
peritonitis are present. On opening the abdominal cavity a rent
1| etin. long is found in the small intestine, with irregular mar-
gins. Resection of a piece of intestine 10 ctm. long. Great
improvement. Faeces, however, continue to pass through the
abdominal wound (a part of which had been left open). On the
tenth day examination is made of the faecal fistula, with the ob-
ject of curing it, but in the evening the patient suddenly col-
lapses, and next day dies from purulent peritonitis. Autopsy
shows that sutures of intestinal wound had separated, that the
separated ends had been shut off by exudation from the perito-
neal cavity, and that the rupture of an adhesion was probably
the cause of death.
Case XXIV. Albanese. — In a man, seventy-six years of
age, who, four days before admission, had received a blow
upon the abdomen, symptoms of acute ileus and peritonitis be-
come developed. On the seventh day after the injury laparot-
omy, the incision being over the colon ascendens. A coil of
strangulated intestine is found, bound by adhesions to the
caecum. These are carefully separated. Good recovery.
Case XXV. Willet ("St. Bartholomew's Hosp. Reports,"
1876, p. 208). — T. F., aged forty-eight, admitted with symptoms
of ruptured bladder, the result of a kick over the pubes. Lapa-
rotomy in rw<nty-four hours after development of peritonitis
(general). Incision five to six inches long, extending from the
umbilicus to the pubes. On opening the abdominal cavity,
several ounces of brown urinous fluid escape; a rent is found
across the fundus of the bladder three inches and a half long.
Edges of rent are brought together by sutures. Sudden death
after a temporary improvement.
Case XXVI. Heath (" Royal Medico-Chirurg. Society," Feb.
25, 1879). — Rupture of bladder. Laparotomy. Rent in bladder
closed by sutures. Death from peritonitis.
Case XXVII. Tait ("Brit. Med. Jour.," 1878, i, p. 677).—
Laparotomy for abdominal tumor, during the presence of acute
peritonitis. The tumor is found to be a Fallopian tube distended
with menstrual blood. Drainage, etc. Perfect recovery. Tait
has done forty ovariotomies during commencing peritonitis.
All the patients recovered.
Case XXVIII. Walter ("Med. and Surg. Reporter," Phila-
delphia, 1862). — Rupture of the bladder in consequence of a
kick on the abdominal wall. As no amelioration follows the
introduction of the catheter, and as signs of peritonitis super-
vene, laparotomy is performed. A rent is discovered at the
fundus of the bladder two inches in extent. Some extravasated
urine in the abdominal cavity. Wound in bladder is not closed,
as no urine is seen to escape. Abdominal wound sutured. Re-
cover!/. Probably the first case in which laparotomy has been
resorted to for acute conditions within the abdomen.
Case XXIX. Chaput ("Jour, de med.," 1880, p. 10;'.).—
Laparotomy for perforation of the vermiform appendix by a
foreign body during the presence of acute peritonitis. Abdomi-
nal cavity filled with foetid pus. Drainage. Death.
References. — Guterbock (" Arch. f. klin. Chirurg.," 1884, 419)
recommends laparotomy and closure of vesical wound in all
cases of rupture of the bladder. McCormac (N. Y. " Med.
Rec," p. 477, 1883) advocates laparotomy in cases of gunshot
wound of the abdomen.
Case XXX. Tilnig ("St. Petersburg, med. Woch.," No. 44,
1884). — Man, aged nineteen, received while at supper a knife
wound four fifths of an inch long in the epigastric region, one
inch to the left of the linea alba and three inches above the
umbilicus. While the wound was being sutured patient vomited
large quantities of a reddish chyme, and afterward pure blood.
Laparotomy. Incision six inches long in median line. On sec-
tion of peritonaeum much blood escapes. The finger introduced
detects a wound in the left gastro-colic ligameut leading to an-
other in the posterior wall of the stomach, through which the
mucous membrane protrudes. The edges of the stomach wound
are brought together by sutures. Owing to the collapsed condi-
tion of the patient, the abdominal cavity can not be thoroughly
cleaned. Abdominal wound closed by Lembert's sutures. Quick
recovery.
Case XXXI. Taylor ("Lancet," 1884, ii, 589).— Girl, aged
fifteen, gives symptoms of acute hydronephrosis. As the symp-
toms increase in severity, laparotomy is determined on. On the
morning of the operation symptoms of collapse set in, the cys-
tic tumor, which was before perceptible on the left side, has also
disappeared, and the abdomen is very tender. As rupture of
the cyst is probable, immediate laparotomy. Incision in median
line. Peritoneal cavity filled with urine. As the point of rup-
ture can not be found, the cyst is opened at another place, and
the edges of the wound are stitched to the abdominal wound.
Recovery with a urinary fistula.
Case XXXII. "Gunshot Wound of the Intestines treated
successfully by Laparotomy with Sutures of the Intestines," by
William T. Bull, M. D. ; read before the New York Surgical So-
ciety, January 27, 1885 ("N. Y. Med. Jour.," Feb. 14, 1885,
p. 184). — W. McE., male, twenty-two years of age, was brought
to the Chambers Street Hospital on the night of November 2,
1884, suffering from a pistol-shot wound of the abdomen. Sev-
enteen hours after the accident laparotomy was performed
under strict antiseptic precautions. On opening the abdominal
cavity, the intestines were found to be wounded in seven
places; these were carefully washed, and the peritoneal edges
were then approximated and the line of sutures carefully rubbed
with iodoform. The bullet was detected at once lodged in the
August 15, 1885.]
BURGH ARB: THE TREATMENT OF ACUTE PERITONITIS.
173
upper surface of the sigmoid flexure. Operation lasted two
hours. Abdominal wound closed with deep silk sutures, and
dressed with an iodoform and borated-cotton dressing.
Six hours after operation cold-water coil applied. After
the eighth day convalescence was uninterrupted save for a few
sinuses in the line of incision, and at the end of eight weeks
the large wound was cicatrized. The functions of the alimen-
tary canal were performed normally, and he was apparently in
good health.
Case XXXIII.— Frederick Treves, F. R. C. S., in a paper
read before the Royal Medical and Surgical Society of London,
on the " Treatment of Peritonitis by Abdominal Section," re-
ports a case in which a large pelvic abscess had burst into the
peritoneal cWjy, followed by acute peritonitis. Laparotomy
under strict antiseptic precautions. Peritonaeum showed ap-
pearances of acute peritonitis. The whole cavity washed out
and a drainage-tube introduced. Patient made a good recovery.
Case XXXIV. — Mr. Howard Marsh, at same meeting, read
the history of a case, the patient being a medical student who
was attacked with symptoms of sudden and acute peritonitis.
Laparotomy; about two pints of foetid pus evacuated. Whole
cavity washed with sol. acid, carbol., 1 to 60, and a drainage-
tube introduced. Recovery.
In the discussion which followed the reading of Treves's
paper, Bryant, Thornton, Powell, Barwell, Goodhart, and Mere-
dith were in perfect accord in commending the practice carried
out in the two cases noted.
Case XXXV. — Omental abscess, rupture into peritoneal
cavity. Laparotomy. Recovery. T. H. Burchard.
On August 20, 1883, I was requested by Dr. Frederick D.
Lente to see Ephraim Wells, aged twenty-five, a colored waiter,
employed in one of the smaller hotels in Saratoga. For some
three weeks Wells had been confined to bed suffering from a
severe cellulitis of the abdominal walls. Several superficial
abscesses had formed, which had been located by Dr. Lente.
He had suffered intense abdominal pain, temperature fluc-
tuating from 101-6° to 104-5°, and was rapidly emaciating. For
six or seven days prior to the present complication his abdomen
had become tympanitic and the pain more diffused. For forty-
eight hours tbere had been excessive hiccough and frequent
retching of green mucus. On the night of August 19th he took
surreptitiously four compound cathartic pills. At seven o'clock
on the morning of the 20th Dr. Lente was summoned, and an
hour later I saw him.
He was lying with legs flexed, abdomen moderately dis-
tended and breathing thirty -two times a minute ; his pulse was
120 and his temperature 102-2°.
Examination showed an indurated condition of the tissues
of the hypogastric and left hypochondriac regions, the integu-
ment being somewhat erysipelatous in appearance. The indu-
rated mass appeared to involve the entire thickness of the ab-
dominal wall, and was about six by seven inches in diameter.
Both Dr. Lente and myself thought we detected deep-seated
fluctuation, and, although a Luer's aspirating needle failed to
give pus, at Dr. Lente's request I proceeded to evacuate the
abscess. Dr. William Curtis, of Philadelphia, gave ether.
My incision was made in the median line (deep-seated fluc-
tuation appearing more distinct there, although the principal
part of the induration was slightly to the left), and extended
from an inch below the ensiform cartilage downward to the
umbilicus.
Just as I reached the linea alba, at a depth of fully two inches
and a half, something was felt to suddenly give way beneath
the hand, as though an abscess had burst within the peritoneal
cavity. Although it was thought the patient would certainly
die, it was determined that what little chance he had depended
upon giving vent to the pus anteriorly. The incision was ex-
tended through the linea alba and into the great omentum,
which was adherent to the abdominal wall and the seat of the
abscess.
Omentum, intestines, and mesentery were matted together
in one inseparable mass, and pus of an extremely foetid odor
welled from the cavity of the belly. I should say fully a quart
escaped.
The patient grew rapidly weaker. Inhalations of ammouia
and amyl and hypodermics of whisky were freely used. Warm
milk-punch was injected per rectum.
The patient rallying, the incision was prolonged below the
umbilicus, so as to get beneath the abscess, and so thoroughly
wash out the abdominal cavity.
Fully a gallon of warm carbolized water (3 per cent.) was
thrown gently in among the matted coils of intestine. The
walls of the abscess cavity were sparingly dusted with iodoform,
and two rubber drainage-tubes were inserted. The upper and
lower ends of the incision were sutured with silver wire; the
median portion above the umbilicus was purposely left open to
permit of free drainage.
A pad of oakum, wrung out in sol. hydrarg. bichlor., 1 to
1,000, was placed over the entire wound, and a light bandage
applied.
The patient rallied poorly from the operation. Hiccough and
vomiting continued the entire afternoon, the pulse most of the
time being scarcely perceptible. 2 p. m., pulse 140, temperature
103-4°, respiration 26; 5 p.m., pulse 136, temperature 104-6°,
respiration 30.
Cracked ice and small portions of champagne frappe were
given by the mouth, and enemas of beef peptonoids and milk
punch were given each four hours. Morphine, atropine, and
digitalis were given hypodermically, p. r. n. Ice-coil on abdo-
men.
August 22d. — 5 a. m., pulse 130, respiration 28, temperature
100-6°. Sleeping quietly. Has had during the past twenty
hours morphine 2^ gr., atropine } gr., tinct. digitalis v\ xl. 4
p.m., pulse 124, respiration 27, temperature 101-4°. Wound
discharging freely. No hiccough or vomiting.
23d. — 8.30 a.m., pulse 118, respiration 24, temperature
100-2°. Comfortable night. 3.30 p. m., pulse 116, respiration
26, temperature 100-4°. Morphine 1^ gr. in twenty-four hours.
Takes peptonized milk and iced champngne.
2Jfth. — Vomited once during the night. General condition
excellent. Wound discharging comparatively little. 9.45 a. m.,
pulse 115, respiration 22, temperature 99-8°.
26th. — Improving in every respect. Abdominal induration
disappearing. Removed one drainage-tube and one stitch. Or-
dered a tonic — iron, quinine, and strychnine.
29th. — Removed all stitches. Incision about one half inch
long. Removed rubber tube, and inserted one of decalcified
bone.
September 2d. — Patient convalescing rapidly. Leaving Sara-
toga to-day. Dr. Lente took entire charge of the case. A few
days after, Dr. Lente returned to Cold Spring, and I never saw
him again alive. I learned, however, that Wells left Saratoga
about the last of September in excellent condition. Most dili-
gent inquiry has failed to find his whereabouts since.
Now, if these forty cases, with twenty-four recoveries,
teach anything, they teach not merely the feasibility of
such operations, but, more than that, they give us legiti-
mate ground for encouragement in fully sixty per cent, of
these otherwise hopeless cases.
In contrast with the foregoing, permit me to give very
briefly the history of my sixth case of perforation of the
174
BURGH A RD: THE TREATMENT OF ACUTE PERITONITIS. [N. Y. Mbd. Joch.,
appendix vermiformis, and, for personal reasons, I desire to
omit all names and dates:
I was requested by Dr. to see Miss in con-
sultation. She was twenty-two years of age, and generally
Lad enjoyed good health. Three months before she had
had an attack of perityphlitis, which had lasted about three
weeks. A small mass of induration, of about the size of a
billiard-ball, was still left. She had had another attack
sixteen months before.
On the evening prior to the present attack she had been
at a party, danced excessively, got overheated, drank con-
siderably of cooling beverages, and in going home and after
she retired had chilly sensations. On awakening about 8
A. m., feeling " uncomfortable in her old spot," she took a
large saline. This was followed by two copious move-
ments. During the second she experienced a sudden sharp,
darting pain in her right side, and immediately fainted.
I saw her about noon. She was then in excellent condi-
tion— pulse 108, temperature 100°, abdomen moderately
distended ; some hiccough and nausea. Pressure over the
tumor produced sharp pains. Stethoscopic examination over
the caecum gave distinct fremitus and crepitation. I diag-
nosticated unhesitatingly perforation of the bowels, and urged
an immediate operation. My advice was not accepted. At
nine the following morning I was summoned hastily, and to
" be prepared to operate." The condition of things had
now entirely changed. The patient was semi-moribund.
Abdomen enormously tympanitic. Pulse 140, and inter-
mittent. Naturally, an operation at this period would have
been worse than useless. The patient died two hours later,
or twenty-seven hours from the commencement of the at-
tack. It was with melancholy interest that I saw the
autopsy reveal a minute perforation at the base of the
appendix not three lines in diameter. The appendix was
bound down by old adhesions. There was the faintest exu-
dation of lymph immediately around the perforation.
Austin Flint, in his last edition, in speaking of septic
peritonitis (Flint's "Practice," p. 590), says: "The time
may come when paracentesis abdominalis will have been
proved to be as applicable to certain cases of peritonitis as
are thoracentesis, injections into the pleural cavity, and a
permanent opening in the chest' in cases of suppurative
pleurisy." In the light of these cases, I submit, Has that
time not already come ?
Regarding the medical treatment of peritonitis, there
are some points of special interest worth considering, and,
first, as to the opium treatment. Opium is our sheet-anchor
in the treatment of peritonitis, and yet, indispensable as the
drug is, there are certain conditions which arise in the course
of the disease in which the drug can only be used with the
greatest caution. The indiscriminate use of opium, even in
peritonitis, is quite capable of doing more harm than good.
The symptoms of peritonitis vary with the extent, sever-
ity, and the causes which produce it. When the disease
develops gradually, as from a pre-existing visceral inflam-
mation, for some time there may be little or no constitu-
tional disturbance. When it develops suddenly, however,
and particularly if from internal traumatism, as hernia, per-
foration, or other intestinal injury, this condition of shock
enters as a very important element in the development of
symptoms, and the treatment must be varied accordingly.
This initial collapse of peritonitis is a subject upon
which too little has been said, and yet its treatment is of
most signal importance. I have seen it persist for hours
after well-pronounced peritonitis had developed, as evi-
denced by increasing meteorism, increasing abdominal ten-
derness, and a rising temperature, and yet the while the
patient lying listless or semi-conscious, with limbs extended,
with features pinched and shrunken, and a pulse scarcely
perceptible.
A most remarkable case of this kind occurred in my
practice a few years since. A young gentleman, John EL
aged about twenty-six or twenty-seven, came to my office
one morning complaining of a left epididymitis. As the
inflammation was of unusual severity, I sent my assistant,
Dr. L. D. Woodbridge, to his home to apply half a dozen
leeches over the cord in the left inguinal region. About
midnight I was summoned to see him, as he was suffering
severely.
Dr. Woodbridge responded to the call and found his
pain was less, but that he was rapidly sinking into a condi-
tion of collapse. At 2 a. m. Dr. Woodbridge wrote that
"Mr. H. was evidently dying." I went at once, and found
my patient unconscious and almost pulseless. His respira-
tions were very shallow, and at times would stop altogether.
His pupils were widely dilated and irresponsive. Superfi-
cies of the body pale and cold. Rectal temperature 96°.
Abdomen greatly distended, and pressure on it would cause
a reflex regurgitant movement in throat and an expression
of pain. During the early afternoon his temperature rose
to 102,6° and he became deeply cyanotic.
Dr. Loomis saw him at 2 p. m., confirmed'the diagnosis
of peritonitis, and said the patient, being then comparatively
pulseless, would certainly die. At 5 p. m., after fifteen
hours' constant labor, keeping up artificial respiration all
the while and feeling that he could survive but a very few
minutes, Dr. Woodbridge and I left the house.
At 6.30 p. m. we were recalled, to find him slowly re-
gaining consciousness. He subsequently fully rallied, passed
through an unusually severe peritonitis, and is now well.
In speaking of treatment, the text-books generally rec-
ommend, "as soon as the unmistakable symptoms of peri-
tonitis are developed, administer at one dose from two
to five grains of opium, or from one half to one grain of
morphine."
And yet physiological experimentation has proved that
collapse, such as existed in this case, is dependent upon
vaso-motor paresis, and the deeper the involvement of the
sympathetic the more profound the collapse.
Now, this is a condition of the system in which opium,
even in moderate doses, is poorly borne. Infinitesimal
doses of morphine in conjunction with atropine, by miti-
gating pain and securing nervous tranquillity, undoubtedly
exert a favorable tonic influence upon the heart. Large
doses increase the paralysis of the cardiac inhibitory center
and still further cripple that organ.
This is no visionary condition of affairs, for I have more
than once seen a heart feebly endeavoring to rally from the
August 15, 1885.J
BURCHARD: THE TREATMENT OF ACUTE PERITONITIS.
175
shock of a commencing peritonitis well-nigh overwhelmed
by a dose of morphine that the text-books would justify, and
one which a" few hours later would be insignificant.
Another and very important fact to be noticed in the
commencement of peritonitis, and governing greatly the
freedom with which opium may be used, is the perplexing
discrepancy that ofttimes exists between the severity of the
pain and the apparent hard, tense, wiry pulse on the one
hand, and, on the other, the very great heart-feebleness.
Under such circumstances, every dose of opium given,
unless guarded by atropine or digitalis, jeopardizes the
heart, and no dose should be administered under such cir-
cumstances without previous careful cardiac auscultation.
There is another condition, developing later in the his-
tory of the disease, in which the administration of morphine
in large doses is equally prejudicial, and upon which condi-
tion current literature is likewise, unfortunately, silent.
I refer to the hypostatic pneumonia which, owing part-
ly to the patient's asthenic condition and partly to pressure
on the lungs from excessive tympanites, is so apt to develop
at that time.
Here, too, we have an important inhibitory center, the
respiratory, paralyzed from carbonic-acid-gas poisoning. In
addition, we have lungs badly compressed, with blood im-
perfectly aerated sluggishly flowing through them ; portions
of the pulmonary structure are consolidated, either from
simple stagnation of the blood or from lobular inflamma-
tion.
At this stage a slight overdose of morphine might arrest
the respiratory act entirely. Yet I have seen its use per-
sisted in under these very conditions.
When the disease has reached this point and cyanosis
begins to develop, I believe little is gaiued from pressing
opium, and it is wise to suspend its administration except
at infrequent intervals, giving it only to meet some special
indication, and guarding it carefully with digitalis, atropine,
or ammonia. At this period stimulating hypodermics should
be freely resorted to ; dry cups to the lungs are of signal
benefit, and inhalations of oxygen often tide us over an
ugly complication.
In a case of peritonitis under my charge last winter —
that of a young lady of twenty, in the third week of ty-
phoid— my assistant, Dr. Henry A. Mandeville, and myself
fought day and night for nearly a week a temperature that
fluctuated from 103° to 106-6°, until at last she went into
unconsciousness from respiratory failure and carbonic-acid
poisoning. Although the cyanosis involved the entire body,
and she had been practically pulseless and unconscious for
eighteen hours, nevertheless, under the atropine and other
stimulants that were injected, and the oxygen inhalations
that were given, she rallied and regained consciousness.
Regarding the use of opium, freedom from pain is the
ideal coudition to be secured, irrespective of the quantity
of the drug administered. When this is attained, sleep
from which a patient can be readily aroused follows as a
natural consequence. Opium, or its alkaloid, morphine,
should be administered. Personally, I prefer the hypoder-
mic administration of morphine, not alone from the sim-
plicity and certainty of its administration, but, what is of
more consequence, the absolute knowledge it gives us of
the exact quantity of the drug our patient is receiving.
Given by the mouth, how much is absorbed and how much
lies dormant in the stomach is purely a matter of conjec-
ture.
Several years since a patient of mine, convalescing from
peritonitis, passed a curious mass at stool several days after
the discontinuance of the drug. Upon examination, this
proved to be a collection of opium pills that had been pre-
pared at one of the most reliable pharmacies in the city.
I am confident that, had this amount of opium been ab-
sorbed, it would have killed my patient, in which event the
death would naturally have been attributed to the perito-
nitis.
Objections have been raised against the combination of
atropine with morphine, it being alleged that the physio-
logical antagonism that naturally exists between these two
drugs tends to render the development of symptoms irregu-
lar, and their interpretation more perplexing and obscure.
Undoubtedly atropine does produce a marked change in
the patient's appearance, and certain very characteristic
changes in the phenomena of the disease ; but these changes,
we believe, are in every way favorable to the patient.
There is no one drug in the treatment of collapse —
whatever be its cause, whether traumatic or from disease
in which more implicit confidence can be placed than in
atropine. Owing to its stimulating action, the heart gains
strength, the respiratory act deepens, and the phenomena
of shock yield in a surprising manner to those of traction.
In the later stages of peritonitis, especially when the heart
and lungs fail and when gastric regurgitations and hiccough
are rapidly exhausting our patient's vitality, I have obtained
results that were simply marvelous from the administration
of one or more hypodermics of atropine, varying in strength
from one sixtieth to one tenth of a grain each, and given
either alone or in combination with morphine, digitalin,
ammonia, or alcohol, according to the special indications
existing.
The contrast in the appearance of two patients — one
being treated with atropine in combination with morphine,
and the other with morphine alone — is most marked, while
in moments of special exigency the value of this drug is
inestimable.
The amount of morphine that should be administered
varies naturally with the patient's susceptibility, the severity
of the disease, and the amount of pain.
Each patient in these particulars is a law to himself, and
no rule could be formulated that, in a general way even,
would apply to individual cases. The remarkable tolerance
of morphine in peritonitis is too well known to require
more than a passing mention, and yet, since adopting the
hypodermic method, I have been surprised to see how little
was generally required, as compared with the immense doses
formerly given by the mouth.
After being brought to a condition of partial narcosis
there have been comparatively few cases, except those of a
septicemic nature, that have required more than two grains
of morphine a day ; although in one case attended by Dr.
Loomis and myself, after giving three doses of two grains
176
WILCOX:
THE OPERATION OF EPISIOTOMY.
[N. Y. Med. Jodk.,
each, hypodermically, an hour apart, I gave one grain,
hypodermically, each hour for twenty-seven consecutive
hours without entirely controlling the pain or materially
reducing the frequency of the respirations, which varied
from twenty-five to thirty a minute. The patient recovered,
having received during the first five days of her sickness
sixty-three grains of morphine hypodermically.
External Applications. — Much has heen said of the effi-
cacy of external applications — used either hot or cold.
Poultices are still used by many. Until within the last
two years I employed them exclusively. Upon what thera-
peutic principle their use was based I did not know then.
I do not know now. Under three conditions only can I
conceive of any physiological reason for their employment:
First, in the commencement of a peritonitis, by their seda-
tive effect upon peripheral nerves, they may assist in lulling
pain; secondly, during the passage of urinary or biliary
calculi, or in intestinal colic, they may assist in relaxing
spasm ; and, lastly, during the stage of decline they may
hasten the absorption of inflammatory products. For these
reasons a poultice is indicated; otherwise they neither con-
trol inflammation, reduce temperature, nor lessen tympanites,
all of which is done, and with perfect comfort to the pa-
tient (provided the temperature of the water is reduced
gradually), by the employment of the ice-coil.
If experimental physiology has taught us anything, it is
that cold applied to peripheral sensory nerves controls the
afflux of blood to those parts supplied by the vaso-motor
nerves that inosculate with such sensory branches.
The sympathetics distributed to the intestines and peri-
tonamm arise from the solar plexus, the sensory filaments
being the lumbar nerves which supply the wall of the ab-
domen. Ice applied to the abdomen constricts the blood-
vessels of the intestines and peritonajum, and it is in the
reflex contraction of these blood-vessels that the benefit
resulting from the application of cold to the abdomen finds
its physiological explanation. Poultices are not curative.
Cold, judiciously employed, lowers temperature, reduces in-
flammation, relieves tympanites, and secures nervous tran-
quillity. There is but one way of employing cold, and that
is by the ice-coil. This can be readily extemporized from
either lead or rubber tubing.
For diet nothing is comparable with peptonized milk,
to which additional cream may be added if desired. Val-
entine's beef-juice, beef-peptonoids, and Leube's meat solu-
tion furnish valuable nitrogenized preparations.
For the relief of tympanites much depends upon whether
the gas is within the cavity of the peritonseum or in the
intestines. If the former, a fine aspirating needle may be
introduced, and with immediate relief. If the latter, a long
tube may be passed up the bowel and an ounce or more of
some warm aromatic solution injected. Gas must not be
expected to escape through a tube occluded with fajces.
Large faecal masses not infrequently prevent the escape
of flatus by blocking up the rectum. Under such circum-
stances a large enema of flaxseed tea, in which some ox-gall
has been dissolved, may be injected with benefit. A patient
of mine, who was once rapidly succumbing to increasing
tympanites, was saved by this simple procedure.
Pneumatic aspiration of the intestine I regard as neither
surgical nor safe.
As in the case Professor Polk, reported at the Obstetri-
cal Society, I have seen gangrenous inflammation with faecal
extravasation follow the puncture.
Turpentine stupes I resort to more out of respect to
tradition than because of any very positive benefit I have
ever seen follow their use in general peritonitis.
When turpentine is pushed to any considerable extent,
I fear damage to the kidneys.
I have seen both strangury and hematuria follow its
external application. In two cases I have noticed a marked
increase of albumin in the urine following its employment.
A discontinuance of the stupes caused a total disappearance
of the albumin in one case, and a considerable reduction in
the other.
Independent of the fact that Bright's disease is of itself
a frequent cause of peritonitis (Habershon's statistics give 63
cases of Bright's disease as the exciting cause of 301 cases
of peritonitis [" Med. Times and Gaz.," I)ec. 13, 1859] ), the
anatomical position of the kidneys renders them prone to
take on inflammation whenever the peritonaeum is inflamed.
Hence I have often questioned if a powerful irritant to the
kidneys — as turpentine is — does not sometimes add addi-
tional irritation to these organs.
Daily and frequent urinary examinations should be
made, for more than once has the timely application of
cups and a digitalis poultice over the kidneys saved for me
the life of a patient who was insidiously developing a ne-
phritis which, without such examinations, would never have
been suspected.
Last, but by no means least, the successful treatment of
peritonitis demands a personal devotion and attention in-
volving complete abnegation of self.
THE OPERATION OF EPISIOTOMY.
By REYNOLD W. WILCOX., M. A., M. D.
The operation of episiotomy does not seem to have re- '
ceived, at the hands of English and American writers on
the subject of obstetrics, the attention to which its merits
entitle it. In the majority of obstetrical treatises the sub-
ject is dismissed in a few lines, or no allusion is made to it.
If, on the contrary, it has attracted the attention of the
author, it is often superficially discussed, or his erroneous
preconceived ideas are apparent in his treatment of this
subject. To one who has seen this operation as one of fre-
quent, even daily occurrence in the lying-in wards of
Vienna, this appears incomprehensible. It is the writer's
intention to briefly point out its advantages and results,
and, if possible, to deduce some impartial conclusions.
Episiotomy is no new operation, nor is it an abandoned
one recently resurrected, but one, although influenced by
the fluctuation of obstetrical opinions, in uninterrupted use
for more than a century. If we read aright, the name was
suggested by Ould, in his " Treatise on Midwifery," in
1742,* although Michaelis was the first to perform it, in
1799. At the next confinement, ten years later, the same
* Parvin, in " Trans, of the Am. Gyn. Soc." for 1882, vol. vii, p. 151.
August 15, 18*5.]
WILCOX: TEE OPERA
TWN OF EPISIOTOMY.
177
perinaeum was yielding and in excellent condition, but
showed a fine cicatrix from the operation.* A little later
we find Elias v. Siebold f strongly advising this operation.
Frequent allusions arc met with in German obstetrical lit-
erature, until we find the most complete exposition of this
operation in an elaborate article, by Crede and Colpe, in the
" Arch. f. Gyn." for 1884. J The operation consists in mak-
ing a small incision, often a subcutaneous one, in the rima
vulvce, and is never an extensive and complete laying open
of the vagina, as has been described or as is often consid-
ered to be the case by those who have not seen it per-
formed. In fact, it hardly deserves to be dignified by the
term " operation " if one looks at it only from the stand-
point of facility of performance and the slight amount of
practice required.
The aim of the operation can best be understood if one
considers the causes of dystocia that arise from conditions
of the soft parts, or can be remedied by operations upon
them. In brief, in performing episiotomy it is intended to
avoid rupture of the perinaeum, arising from all causes ex-
cept those referable to the force and character of the pains.
The causes of perineal rupture are :
I. From condition of the soft parts.
a. Rigidity, by which we mean that the perinamm shall
be anatomically normal — the perinaeum of inexperienced ob-
stetricians. In this case the vaginal orifice can be dilated
to the size of the child's head, yet the hyperesthesia of the
muscles prevents this end.*
b. A second condition to which this same term is ap-
plied when the vaginal outlet is anatomically incapable of
full distension, when the surrounding tissues are not fully
developed, or, as in old priuiiparae, the tissues are inelastic.
c. A condition of the muscular fibers which renders
them unable to bear moderate strain, a state of affairs found
in tissues for a long time subject to congestions, indeed
analogous to the fatty infiltrations and degenerations. ||
d. Excessive width or length of the perinaeum. A
II. From condition of the bony parts.
a. The narrow pubic arch, "male pelvis," or, what
amounts practically to the same result, a thickened condi-
tion of the urethral structures.
b. Too little inclination of the pelvis.^
III. On the part of the child.
«. Incompressibility or excessive size of the head.
b. Malpositions and malpresentations.
Lastly, the feeling on the part of the accoucheur that, " if
laceration is inevitable, treatment to prevent it can be of no
avail." J In the three classes mentioned it is assumed that
the conditions present do not exist to such an extent that
birth is not possible without other operative or instrumental
interference. It is to hasten the result and to avoid the
* Crede u. Colpe, "Arch. f. Gyn.," 1 Hft., 1884, S. 150.
f "Lucina," 1810, vol. vi, quoted by Crede u. Colpe, loc. cit.
% S. 148, u. ff.
* Carter, "Med. News," 1883, v. 43, pp. 66 et seq.
[ Carter, loc. cit.
A Baker, "Trans, of the Med. Soc. of Penn.," 1882, xiv, p. 236.
Q Cf. papers of Baker and Carter above quoted.
% Duncan, " Papers on the Female Perineum," London, 1879, p. 16.
unfortunate consequences of perineal rupture that this op-
eration is demanded.
That unavoidable perineal rupture takes place is proved
conclusively by the records of clinics where no one is al-
lowed to practice midwifery until shown competent by
examination.
Winckel * states that ten per cent, of all patients suffer-
laceration. While Hecker,f in over twelve thousand cases,
found three and sixty-six hundredths per cent, of lacerations,
Spiegelberg,J among three thousand cases, found tears over
two and a half centimetres long (one inch) in three and one
half per cent, of cases; Preiter's* cases, over seven thou-
sand in number, showed tears in three and forty-seven hun-
dredths per cent, of their number.
Considering prirniparae alone, the percentage is much
higher, being, according to K. Schroeder,|| twenty-four and
four hundredths per cent, (deliveries in side position) ; ac-
cording to Hippold,A eighteen and seven tenths per cent.
■In elderly prirniparae, as shown by Ahlfeld,^ about thirty
per cent. ; by Hecker,J fourteen per cent. ; by Cohnstein,t
three and fifty-eight hundredths per cent.
The relative frequency of lacerations in prirniparae and
multiparas may be inferred from the following figures: B.
Schroeder % thirty-four and one half and nine, Kleinwach-
ter ** thirty-four and ten, Olshausen f f twenty-one and one
tenth and four and seven tenths per cent., respectively. The
last authority, quoted in Lusk,JJ believes that fifteen per
cent, is not too great for unpreventable tears due to defec-
tive distensibility of the perinamm and disproportionate size
of the head of the child in prirniparae, although he considers
two per cent, too high for multipara?.
The advantages of episiotomy are not disputed in cases
of atresia vaginae or in any structural contraction.** Grant-
ing that a laceration is inevitable, the operation removes it
from the median line and locates it in the exact position
chosen by the accoucheur. This avoids the danger of a lacera-
tion through the sphincter ani, and also relieves the strain
upon the recto-vaginal septum, preventing a central rup-
ture.! || Also, as is stated by Elder, AA episiotomy limits the
extent of the lesion. In Crede's cases not a single case of
total rupture occurred.
When one compares the spontaneous lacerations, irregu-
lar in depth and outline, with the subcutaneous incisions or
of Midwifery," 1813, vol. ii, p. 14.
Illl Lusk, op. cit, p. 210; Glisan, "Textb. of Midwifery," 1881, p.
368.
AA London "Lancet," 1884, i, p. 1160.
* " Die Path. u. Ther. des Wocheubettes," 2te Auf., S. 44.
f " Arch. f. Gyn.," Bd. vii, S. 458.
% "Lehrb. der Geburtsh.," 1878, S. 628.
* Quoted in Winckel, op. cit.
I "Manual of Midwifery," Am. trans., 1878, p. 93.
A Quoted in Credo u. Colpe, op. cit., S. 149.
v " Arch. f. Gyn.," Bd. xiv, S. 514.
| " Arch. f. Gyn?," Bd. vii, S. 452.
I " Arch. f. Gyn.," Bd. iv, S. 509.
J Quoted in Credd u. Colpe, lot: cit.
** " Grundriss der Geburtsh.," 1877, S. 304.
ff Volkmann's "Sammlung kliniscfaer Vortrage," No. 41, S. 360.
XX "Science and Art of Midwifery," 1882, p. 207.
** C. v. Braun, " Lehrb. der Gyn.," 1881, S. 726, and Burns, " Priu.
178
WILCOX: THE OPE RATON OF EPISIOTOMY.
[N. Y. Med. Jocr.,
the clean-cut operations (the daih- practice in Vienna), he
can not but mark the difference and marvel that so simple
a procedure has attracted so little attention in America.
Not only because the incisions are subcutaneous do they
unite so readily, often by first intention, without subsequent
attention, as in Spaeth's wards at Vienna, but the fact that
the edges are clean-cut is important.* Yet Playfair, in his
"Svstem of Midwifery," 1880, has apparently changed his
opinion, for, while he nowr admits, as every one does, that
incised wounds heal more rapidly than lacerated ones, he
believes that a distended perina-um ruptures with edges as
clean-cut as if by a knife. f The testimony of the crynse-
cologist who meets with extensive cicatrices, deep and
irregular in outline, in his daily work, proves that a clean-
cut spontaneous laceration must be very rare — far more so
than our author would have us believe.
A third reason for the more rapid process of healing
after this operation is that the gaping observed from retrac-
tion of the transversus perinsei muscle in spontaneous lacera-
tion is absent. J Although the passage of lochia over an open
wound is often unattended by general symptoms or re-
tarded healing, yet the artificial lesion obviates any possible
danger from this source so long as the dorsal position is
maintained.
Finally, the deformity of the vulva is by no means so
great as after spontaneous rupture.*
In marked contrast to the anxiety shown in the paper
by Crede as to the patient's future is that inferred from the
statements, so often met with, more or less frankly made,
" that perineal tears are of no significance if they heal with-
out surgical interference." || Perhaps even more unfor-
tunate, and fraught with far more disastrous consequences
to the patient, is the opinion occasionally met with that these
lacerations are very rare, and in the observers' personal ex-
perience never have they been encountered.A Happily, such
opinions are fast becoming less frequent, and one may hope
that the practitioners may be led to take measures to pre-
vent what they have hitherto left for others to cure.
It has been justly urged that we can not certainly pre-
dict that a laceration will occur, and therefore this opera-
tion has no clearly defined indications. In an earlier por-
tion of this paper statistics from various sources are quoted
showing that, under any and all systems of treatment, lacera-
tions must occur; but to state that one who has had thor-
ough practical instruction — and none other should be al-
lowed to practice midwifery — can not with reasonable cer-
tainty predict that the perinseum, if left to itself, will be
lacerated, is, to say the least, begging the question. To
operate only when the fact that the accident will occur is
absolutely certain would be to debar surgical interference,
not only in this, but in every other department of medicine.
It is true that we must have a wound when we perform this
* Glisan, Lusk, loc. cit; Leishman, " Syst. of Midwifery," 1875, p.
573; Playfair, " Handb. of Obstet. Operations," 1865, p. 173.
f P. 282. Cf. Duncan, op. cit., p. 23, and Ahlfeld, " Arch. f. Gyn.,"
Bd. iv, 8. 616.
\ Lusk, op. cit., p. 210.
* Crede u. Colpe, he. cit., S. 165.
| Charpentier, " Traite prat, des accouchements," 1883, t. ii, p. 225.
A Cf. Griswold, "X. E. Med. Monthly," 1883-'84, pp. 455, 456.
operation; but in Crede and C.'olpe's cases {loc. cit., S. 159)
puerperal ulcers (episiotomy wounds healing by granulation)
occurred only nine times in two hundred and seventy-one
cases of operation, but little significance need be attached
to this statement. It is also true that the wound may be a
point for general infection, but the relative probability of
this in a wound not exposed to the lochia, as compared
with the sloughing, granulating wounds of a lacerated peri-
nseum bathed in a decomposing discharge, is easy to deter-
mine. Further, the wounds most dangerous as regards gen-
eral symptoms are those about the cervix, and not the ex-
ternal ones. That this operation does not prolong the puer-
perium will be shown in the figures to be quoted hereafter.
The operation causes pain, very slight in amount if it be
properly done, but by no means to be compared to the pain
that it saves by shortening the period of labor and by sub-
stituting a rapidly healing for a slowly suppurating wound.
Apparently Adolphus * is totally misinformed as to the
character of this operation when he advises the timely use
of the forceps, which will render this operation needless,
since, even if a perineal laceration could be avoided, a doubt-
ful contingency, the forceps operation is by far more severe
than episiotomy.
The weightiest argument of all against episiotomy is the
fact that it will not always prevent a laceration. In Crede's
cases the laceration occurred in one and four tenths per
cent, of his episiotomies, a small percentage indeed when
one considers the value of the operation. Leishman's state-
ment,! that the incision will always be extended as the head
advances, is unsupported by the facts and is contrary to our
own experience. It is conceded that we can not always
estimate the extent of the laceration ; J thus we can not
always avoid slight addition to the incision ; but even this
is far preferable to the spontaneous laceration. The per-
centage of extensions given above is far too small to con-
demn the operation.
In performing episiotomy, the left lateral position for
the patient is preferable, since the advance of the child is
then under perfect control.* The instrument used by
Michaelis was a Pott's bistoury ; in Leipsic formerly Coop-
er's scissors, now the usual straight scissors are employed.
In Vienna the ordinary blunt-pointed bistoury is employed.
Leishman || remarks that the finger-nail may be used, " as
has been practiced by some of the most distinguished ac-
coucheurs," a fitting commentary upon his knowledge of the
operation. The time of the performance of the operation
is of no little importance ; according to Crede and Colpe,A
the incision should be made immediately after the acme of
the pain, because then one knows exactly the length of the
cut, and it gives rise to less pain, whereas, if it be made
before or during the pain, a sudden and severe labor-pain
may be set up and the head be suddenly forced into the
world, and the incision be converted into a rupture. On
* " Jour, of the Am. Med. Ass.," ii, p. 526.
f Op. cit., p. 573.
\ Schroeder, op. cit., p. 93.
* McGaughey, " Am. Jour, of Obstet.," v, xviii, p. 589.
| Op. cit., p. 280.
A Loc. cit., S. 152.
August 15, 1885.]
WILCOX: THE OPERATION OF EPISIOTOMT.
179
the contrary, Lusk* advises that it be made at the begin-
ning or end of the contraction. The incision is made two
to three centimetres (three fourths to one inch and a fourth)
above the frenulum,! toward the tuber ischii — in other
words, perpendicular to therima. \ In the Vienna wards it is
generally submucous or subcutaneous. Spiegelberg * advises
that the open wound be made chiefly in the shin. The
length of the incision is fairly given as from one to three
centimetres, by Lusk || as not over three fourths of an inch.
One incision only is recommended by Crede and Colpe, to be
upon the side which bulges most,A while Carl BraunQ and
Schroeder $ seem to prefer the bilateral. The structures
divided are, omitting the skin or vaginal mucous membrane
the so-called constrictor cunni,^ or, as Lusk J explains, the,
resisting ring formed by the constrictor cunni, transversus
perinsei, and sometimes the levator ani.
To recapitulate : The patient being in the ordinary side
position, the operator, controlling the advance of the child's
head with his left hand, takes the blunt-pointed, straight
bistoury in his right hand. He inserts it, at the commence-
ment of a labor-pain, between the presenting head and the
thinned edge of the vulvar outlet, flatwise, and where the
outlet bulges most, generally at the distance above indi-
cated from the commissure. The bistoury is held in this
position during the increase and until the acme of the pain,
the left hand being likewise kept in place. Immediately
after the acme has been reached the edge of the bistoury is
turned at a right angle to the edge of the vulva, the head
being prevented from being forced out by a sudden exacer-
bation of the pain ; the incision is made outward, from one
half to one inch, through the resisting structures. The
labor now is conducted as usual, the head, as a rule, passing
out at the next pain. In most cases no after-treatment is
required, as the wounds almost invariably close by first in-
tention if carefully cleansed. If the operator believes the
suture to be necessary, it is done in the following manner :
The first suture should enter at the junction of the skin and
mucous membrane, at the upper angle of the wound, com-
ing out at the corresponding lower angle, and be tied. The
second suture is to cover in the two small surfaces left, the
one in the skin and the other in the vagina. This suture
passes through the skin into the vagina, over the vaginal
wound, out through the skin, and is tied over the skin
wound. Iodoform dressing is then applied. The sutures
are removed about the sixth day, and one will find, with
difficulty, a fine cicatrix, if he examines the parts, at the end
of the third week.
In presenting the numerical results of this operation,
the writer is indebted to the excellent paper of Crede and
Colpe, as indeed all others who are interested in this pro-
cedure must be. One of the strongest objections to this
operation has been that it offers a point for general infec-
tion. That infection more frequently results from coinci-
* Op. cit., p. 210. f Crede u. Colpe, op. cit., S. 151.
X Kleinwachter, op. cit., S. 305. * Op. cit., S. 3*73.
|| Op. cit., pp. 210, 211.
A Ballandiu, quoted by Crede, loc. cit., S. 152.
v Op. cit., S. 726. % Op. cit., p. 93.
1 C. v. Braun, op. cit, S. 726. % Op. cit., p. 210.
dent tears in the vagina or cervix is stated above ; the obser-
vations in the Leipsic clinic confirm this view, there being a
difference of only three tenths of one per cent, in cases of
puerperal fever in patients suffering from injured perinseum
over those occurring when the perinseum was intact. Indeed,
among the fatal cases of puerperal fever, two hundredths of
one per cent, represent the difference of death-rate in favor of
injured perinsea, conclusively showing that the condition of
the perinseum had nothing to do with either mild or severe
cases of puerperal fever. Nor are figures wanting to show
that this operation shortens the time of convalescence, for
the cases of episiotomy that remained over fourteen days
were twenty-one and two tenths per cent.; cases of rup-
tured perinseum remaining over the above time, twenty-six
and nine tenths per cent; cases of rupture in spite of episi-
otomy remaining over the same time were thirty-one per
cent, of the whole number. The percentage of all cases of
injured perinsea remaining over fourteen days in the hospital
was twenty-three and one tenth, while the corresponding-
percentage for episiotomy cases was twenty-one and two
tenths. That is to say, the percentage of patients under-
going the operation of episiotomy, and who, without this
operation, would have suffered rupture of the perinseum,
whose convalescence necessitated a stay of more than four-
teen days in the hospital, was less than that of ruptured
perinsea requiring the same length of after-treatment.
To explain the cases of rupture in spite of episiotomy,
twenty-nine in number, it is necessary to state the condi-
tions present. Fifteen of these patients gave birth to chil-
dren of over thirty-five hundred grammes (seven and seven
tenths pounds), four suffered from vaginitis granulosa, three
underwent forceps operations, and in one case the blades
were badly placed. Of the remaining fourteen cases, three
were vaginitis granulosa, three syphilis, one was an antero-
frontal presentation, one a case of hydrocephalus, two tears
were caused by the shoulder, thus leaving four cases in
which rupture took place after incision, which only shows
that in these four cases the incision was not long enough,
and is in no case to be considered an argument against the
operation.
No further argument seems to be necessary to show that
incision is preferable to spontaneous rupture.
To demonstrate the effect of the operation upon the
frequency of rupture, the statistics of one thousand cases of
primiparse, delivered by five successive assistants at Leipsic,
are here given :
Percentage
Percentage
of Incisions.
of Ruptures
10-3
20-7
20-4
118
Third "
263
11
Fourth "
28-5
7-4
Fifth " i
32
7-2
From this the conclusion may be drawn that, as the
operation of episiotomy becomes frequent, in just the same
ratio do perinatal ruptures become infrequent.
1050 Lexington Avenue, January, 1S85.
Note. — Since the foregoing was written, an article on
tliis subject, by Dr. W. P. Manton, has appeared in the
180
MAXSON: TYPHOID OR ENTERIC FEVER.
[ST. Y. Med. Joun.,
"American Journal of Obstetrics," vol. xviii, pp. 225 et seq.
It is hoped that others may study out this operation, until
the attention of American obstetricians has been called to
its value.
TYPHOID OK ENTERIC FEVER.
(ABORTIVE TREATMENT.)
By EDWIN R. MAXSON, M. D., A. M., LL. D.,
SYRACUSE, N. T.
Definition. — Typhoid or enteric is a continued fever,
and, when not arrested, is liable to be of long duration, may
be attended with diarrhoea, and is usually characterized by
intestinal lesions, an eruption of small rose spots, sudamina,
and often enlargement of the spleen and mesenteric glands.
Symptoms. — At first the appetite may fail, the tongue
become furred, and very soon there is headache with gen-
eral depression, and muscular weakness with wandering
pains, the patient being indisposed for exertion of any
kind, mental or physical.
After an indefinite prolongation of these premonitory
symptoms there may be chilliness, more or less marked.
The headache increases, being sometimes attended with
epistaxis. The prostration becomes greater, with sensations
of chilliness along the back, alternating with flushes of
heat.
If typhoid fever is prevailing in the vicinity, or the
patient has been exposed to the causes known or supposed
to produce the disease, the physician, if a person of ordi-
nary sagacity and diagnostic ability, will suspect the dis-
ease. If the suspicion is well founded, in addition to the
symptoms already stated, there will be found the usual
symptoms of the febrile state. The pulse is increased in
frequency ; the temperature rises ; the tongue is coated of
a white or yellowish color, of various degrees of thickness ;
and the urine is diminished in quantity and high colored,
as a rule.
If, on further examination, no local inflammation can be
found to account for the pyrexia, and the patient looks
heavy and oppressed, being more prostrated than the dura-
tion of the illness, without the influence of the typhoid
poison, w ould be likely to have caused ; aud if the abdomen
is tumid, with slight tenderness over the right iliac fossa, or
even if there is not, with the other typhoid or entjric
symptoms — the physician of discretion, prudence, and com-
mon sense will not need to wait for further symptoms, which
will, of course, be developed at a later stage of the disease,
the result of a continuance rather than essential symptoms
of the disease, but will resort to proper means for its
arrest. For he may thus destroy the poison, reduce the tem-
perature by gentle perspiration, subdue the intestinal in-
cipient disease, equalize the circulation, sustain the sinking
powers of the system, and very generally thus arrest not
only the local but the general disease.
But when these plain indications are not fulfilled, or if
the attempt fails, as may sometimes happen as the disease
progresses, other symptoms are developed, as might be ex-
pected.
The temperature rises from day to day, being from one
to two degrees higher in the evening than in the morning,
by the third or fourth day being 103° or 104° F., perhaps,
as a rule. And by the end of the first week there will have
been developed the symptoms peculiar to the continuance of
the disea«e, as the flushed face, pulse from 80 to 120, often
a cough, tumid abdomen, a gurgling of liquid with gas, and
slight tenderness in the right iliac fossa, with either consti-
pation or diarrhoea, turbid urine, and sometimes the appear-
ance of small rose spots of the size of a pin-head over the
abdomen and chest.
By the end of the second week sudamina will usually
have appeared. The patient may lie mostly on the back,
red patches being on the cheeks. The hands have become
unsteady, delirium may attend, and the sudamina may have
extended over the chest, neck, and other parts of the body.
The spleen may become enlarged, and the diarrhoea, if pres-
ent, more troublesome ; and from the latter part of the sec-
ond week onward various complications, as pneumonia,
haemorrhage, or perforation from intestinal ulceration, may
occur.
By the end of the third week the patient may be deaf,
dull of comprehension, and half unconscious. The body
becomes emaciated, the skin harsh, the muscles wasted, the
tendons contracting or rising up, and, if the disease passes
on uncontrolled, the tongue becomes dry and dark, the pulse
indistinct, the heart weak, the abdomen distended, the stools
involuntary, and the patient generally, either with retention
or incontinence of urine, passes on to dissolution, either by
asthenia or else from some local lesion or complication^
as haemorrhage, perforation, peritonitis, albuminuria, pneu-
monia, pulmonary gangrene, pleurisy, thrombosis, embolism,
or suppurative parotitis, which may have supervened.
But, should the patient rally, the temperature gradually
falls, the pulse becomes less frequent and more distinct, the
tongue cleans, the abdomen subsides, the diarrhoea ceases,,
and the strength gradually returns, subject, of course, to
relapse and various accidental complications that may arise.
Diagnosis. — When typhoid or enteric fever is prevail-
ing in a locality especially, or, when it has not been pre-
vailing, if the patient has been exposed to influences known
or supposed to produce the disease, and there are symp-
toms of unaccountable weakness, with loss of appetite and
a look of illness and prostration not dependent upon some
local inflammation and altogether disproportionate to any
assignable cause other than the typhoid poison, the disease
should be suspected.
If on a careful examination, now, not only local inflam-
mations, but tubercular meningitis, acute pulmonary tuber-
culosis, gastro-intestinal catarrh, pyaemia, ulcerative endo-
carditis, etc., can be excluded, and, in addition to the
symptoms already enumerated, the patient has a severe
headache with epistaxis, and a temperature of 101° or 102°
F. in the morning, or at evening 103° or 104°, the case
may very safely be regarded as typhoid or enteric fever ;
and an effort should be made for an arrest of the disease.
If the disease can be arrested at this stage, no further
symptoms peculiar to it need be developed. But, if not
arrested the first week, there may be a diarrhoea, tympanites,
the rose-colored eruption by the tenth and sudamina by the
August 15, 1885.]
HAXSON: TYPHOID OR ENTERIC FEVER.
181
fourteenth day, obtuseness of hearing, delirium, coma, get-
ting down in bed, confirmatory but not necessary for correct
diagnosis, being rather consequences of a continuance than
necessary symptoms of the disease, if arrested during the
first week. Taking, then, all these precautions, it is my
opinion that very few, if any, mistakes need be made in the
early diagnosis of typhoid or enteric continued fever.
Causes. — It is probable that a multitude of causes may
operate in predisposing to typhoid or enteric continued
fever — such as hereditary predisposition, age, violent physic-
al exertion, damp sleeping-rooms, impure confined air, in-
sufficient clothing, scanty or unwholesome food, impure
water, filth, great depression of spirits, taking food at un-
seasonable hours, the use of tobacco, drunkenness, and the
entire train of depressing influences whereby the system
may be reduced to a condition in which the fluids and
solid tissues of the body are in a more or less abnormal
state, deranging the cutaneous, alimentary, and other func-
tions.
The exciting cause of typhoid or enteric fever, doubt-
less, consists of a poison generally derived from a pre-
existing case, probably the typhoid bacillus, which has been
found in the lymphatics, blood, and tissues, but sometimes
arising, as all contagious diseases did originally, from an
equivalent poison, " generated anew by the decomposition
of sewage " and "of other forms of animal filth." In either
case the typhoid poison is "reproduced in the system dur-
ing the fever, and it appears that its chief, if not exclusive,
outlet is in the intestinal discharges."
But while, however, the contagium may doubtless be
present in the fasces when voided, its virulence appears to be
heightened by exposure, warmth, stagnation, and accumu-
lation, probably by a sort of fermentation, which may go
on indefinitely, the product becoming mingled with water,
milk, and other liquids and even solids, thus producing,
especially in towns, quite a general prevalence of the disease.
It is probable, however, that the contagium may be generated
by the " fermentation of faecal matters, independent of any
specific germ introduced in typhoid evacuations," precisely
as in the first cases which occurred at the origin of the dis-
ease, as already suggested.
The most common vehicle of the poison appears to be
drinking water, contaminated through sewage, either when
drank alone or with milk with which it has beeii mixed.
Anatomical Characters. — While the " primary change
is in the blood," and in most fatal cases local congestions
and inflammations are met with in the lungs and other or-
gans, the " special and characteristic lesions are those taking
place in the intestines and mesenteric glands."
The intestinal mucous membrane of the ileum usually
" presents the appearance of acute catarrh," the chief seat
of morbid changes, however, being in Peyer's patches, con-
sisting of an infiltration of the glands, followed by ulceration.
It appears probable that the first few days of the disease
are attended with congestion and irritation, with, perhaps,
slight infiltration. Afterward, if not arrested, infiltration
goes on into incipient ulceration, and ultimately to exten-
sive ulceration or resolution.
These stages, perhaps, occupy, as a rule, about a week
each in cases not arrested. And it appears that the patches
first affected are those " at the lower end of the ileum, near
the ileo-csecal valve," the lesions here being the most exten-
sive and farthest advanced. The ulcerations may involve
only the superficial layer of the mucous membrane, or its
entire thickness, and in some cases the muscular and even
peritoneal covering may be implicated, with or without per-
foration. Small points of extra-glandular ulceration may
also be found scattered along the mucous membrane of the
small and even large intestines. The mesenteric glands are
also more or less enlarged, being firm and of a pinkish
color. The spleen may also be found enlarged.
Pathology. — Taking into account an hereditary or ac-
cidental predisposition, the typhoid poison from a previous
case, or generated anew from animal filth, sewage, etc., in-
troduced into the system in drinking-water or otherwise,
once in the blood, doubtless not only directly depraves that
fluid, but, being carried by it through the brain and all the
tissues, prostration — attended with more or less chilliness,
and this followed by fever, headache, a torpid skin and
liver, with consequent gastro-intestinal irritation, congestion,
inflammation, and, if not arrested, ulceration — may be the
result, the symptoms, developed during advanced stages of
the disease, being a result of its continuance rather than es-
sential to the disease if arrested.
Prognosis. — While the poison of typhoid or enteric
fever, operating upon a system fearfully predisposed, may,
in some cases with bad surroundings, so far deprave the
blood, depress the nervous system, and derange the various
functions as to render an arrest or even ultimate cure of the
disease beyond the power of human skill, I can readily
believe, especially if neglected during the early stages, two
of which I have had the painful experience of treating dur-
ing the past ten years; I as firmly believe, from careful ob-
servation during that time in a large number of cases, that,
with good surroundings, proper care, and judicious treat-
ment in season, nearly every well-marked case may be
arrested so as not to require further personal attendance
within one week, and on strictly rational, common-sense
principles.
Treatment. — On diagnosticating a case of typhoid or
enteric continued fever, the blood is found poisoned, the
nervous system prostrated from the poison and inefficiency
of the depraved blood, the skin and liver are torpid from
the same cause, and, as a consequence of all this, the tho-
racic, abdominal, and pelvic viscera, including the gastro-
intestinal mucous membrane, and especially Peyer's glands,
from the ileo-csecal valve upward, are in a more or less con-
gested, irritated, and inflamed condition ; and, from a want
of due exhalation from the skin, animal heat accumulates,
raising the temperature to from 101° to 104° F.
The indications, then, are plainly : to destroy or neu-
tralize the poison in the blood ; unload the liver ; call the
skin into action, thus reducing animal heat; to call the cir-
culation to the extremities ; to sustitin the powers of the
system; to subdue abdominal, thoracic, and other irrita-
tions, and especially gastro-intestinal ; to suitably nourish ;
and to keep the patient properly encouraged.
Now, while there are many agencies by which some of
182
DIX: ALCOHOL, RHEUMATISM, AND PHTHISIS.
[N. Y. Med. Jouk.,
these indications may be fulfilled, I will state only the
means which I have found the most convenient and effectu-
al, and by which I have succeeded in arresting within one
week nearly every case clearly diagnosticated as typhoid or
enteric fever that I have treated during the past ten years.
To destroy the poison in the blood I give to an adult
four grains of the sulphocarbolate of sodium every six
hours — at 6, 12, and 6 o'clock — dissolved in a teaspoonful
of water.
To sustain the sinking powers of the system, and as a
further antiseptic, two grains of cinchonidine with ten drops
of the muriated tincture of iron are given every six hours,
alternating with the sulphocarbolate, in four ounces of warm
crust-coffee without milk; and these medicines are contin-
ued for at least a week after discontinuing my visits, the
doses being gradually diminished at the last.
To unload the liver I give an improved compound ca-
thartic pill at first, and then give one a day if the bowels
are confined ; but, if not, a grain pill of leptandrin instead
till the tongue cleans off, and afterward one only of either,
as required for constipation.
To call the circulation to the extremities and the skin
into action, thereby reducing animal heat, as it becomes
latent in the evaporation of perspirable matter from the
surface of the body, a warm foot-bath is used morning and
evening till the fever is arrested and the skin becomes soft
and of a normal degree of heat, as it generally will within
three days by the aid also of warm drinks required for nour-
ishment, and a strict avoidance of everything cold, inter-
nally and externally.
But should the headache continue in spite of all this,
which is rarely the case, a teaspoonful of blood is taken
from the back of the neck by cups, apd repeated if neces-
sary, or blisters applied back of the ears or neck.
To subdue thoracic, abdominal, and other irritations, I
apply daily from the very first warm sinapisms over the
chest and entire abdomen mornings and evenings, taking
care not to blister but to keep as near to it as may be ne-
cessary, and continue them till every symptom of the local
and general disease has disappeared.
Avoiding cold, the patient takes only warm crust-coffee,
one half milk, for drink and nourishment, thus favoring the
sensible and insensible perspiration ; plain nourishing food,
at meal times only, when tolerated, being allowed with tea
if desired.
To keep up the spirits, the patient is kept dressed and
out of bed days as far as consistent with safety, being al-
lowed to recline on a lounge or to occupy an easy-chair,
thus securing better sleep nights.
Here, then, my abortive treatment of typhoid or enteric
continued fever really ends. But should a case, from neg-
lect, bad surroundings, or inefficient early treatment, continue
on for more than a week, I would treat such local inflam-
mations as might have arisen before or in spite of treat-
ment by cups, blisters, etc., and the gastro-intestinal disease
especially by blisters to the epigastrium and abdomen if
necessary. And the only addition I should make to the
abortive treatment already suggested — except to meet
emergencies, as diarrhoea, haemorrhages, etc. — would be to
give with the iron and cinchonidine eight drops of turpen-
tine, in emulsion, as an alterative for the gastro-intestinal
disease, and two drops of the tincture of nux vomica with
the sulphocarbolate, as a tonic for the digestive organs and
nervous system, meeting, of course, any other indications
that might arise from a continuance of the disease on strictly
rational common-sense principles.
Concluding Remarks. — It may not be improper to add,
in conclusion, that the treatment of typhoid or enteric con-
tinued fever here suggested has been arrived at by careful
observation for a term of years, my success in arriving at
the abortive treatment having been largely due to my obser-
vations with Prof. Lister, in the Royal Infirmary of Glas-
gow, in 1867, bearing on antiseptics, before the typhoid
bacillus was known as the probable cause of the disease,
though according admirably with that view as now generally
held.
I have found, however, that, in order to succeed in the
abortive treatment, the warm foot-baths must be regularly
had and continued each time till there is a gentle perspira-
tion, the sinapisms being kept on long enough each time to
insure a continued redness all over the abdomen and chest ;
also to guard against pulmonary complications as well as to
arrest the intestinal disease, though short of blisteriug ; and
that the drinks must be restricted rigidly to warm crust-
coffee, half milk, with warm tea at meal hours-, if desired,
half milk; absolutely nothing else to be taken into the mouth
except such suitable warm digestible food as may be proper
at meal hours only, as eggs, toast, etc., and the plain anti-
septics, tonics, and laxatives suggested, or their equivalents,
though I have found these remedies the most convenient
and successful, and therefore recommend them. Finally, I
may state here that I have found a corresponding course of
abortive antiseptic treatment available in all putrid fevers —
as typhus, diphtheria, spotted fever, etc. — and cutting short
scarlet fever and measles nearly one half.
No. 208 Madison Street, Syracuse, N. Y., May 25, 1885.
ON THE CORRELATION OF ALCOHOL
RHEUMATISM, AND PHTHISIS.
By TANDY L. DIX, M. D.,
8HELBYTELLE, KT.
Owing to the feverish state of the public mind as touch-
ing the temperance question, he who approaches any propo-
sition looking to the encouragement or supplying an excuse
for the use of alcoholic drinks is regarded as perpetrating
an act of temerity. But science is positive in presenting
facts which, as well as the laws pertaining thereunto, must
be strictly observed ; and, however desirable it may be to
retard the devastation which is being wrought in our midst
by the abuse of alcoholic drinks, science can not compromise
herself for the sake of expediency, as some moralists do
when they teach that the wine mentioned in the Testament
was not an intoxicating drink. And he who follows the
teachings of science can not err. It is not our intention to
produce arguments either for or against temperance, but
strictly in the interest of science. The medical man who
lets his predilections influence his views in regard to the
August 15, 1885.J
MX: ALCOHOL, RHEUMATISM, AND PHTHISIS.
183
chemical and physiological action of alcohol within the hu-
man economy is more dangerous to the community tban
alcohol itself.
In the course of my professional duties my attention
was specially called to this subject, and, upon reflection,
several reasons presented themselves which favored the
proposition that those who use alcoholic drinks enjoy, to
some extent, an immunity from rheumatism and phthisis. In
order to learn whether facts would tend to confirm or refute
this proposition as regards rheumatism, I have considered
every case of indulgence within the scope of my acquaint-
ance and memory, and have drawn upon the experience and
observation of as many physicians and laymen as my oppor-
tunity and acquaintance would permit. I have also considered
cases of rheumatism as regards the habits of the patients.
In the reckoning, drinkers who suffered with rheumatism
which was attributable to specific causes have been omitted.
In gathering information concerning this topic, it is
necessary to make close inquiry, and to consider the views
which the informant may entertain in regard to the liquor
traffic. A bartender can not discover rheumatism among
his customers, and the extreme temperance man can discover
rheumatism in every one who indulges. The information
that I have been able to obtain confirms the proposition,
and, if the proposition is true, it must be founded upon
physiological and chemical facts which I propose to con-
sider as follows.
In approaching this topic, the first inquiry that engages
our attention is the physiological and chemical origin and
elimination of the very complex substance — fibrin. Fibrin
is found in its most perfectly developed state as its exists
in the muscles and fibroid tissues, and is held by the blood
in solution as a product of both progressive and retrogres-
sive metamorphosis. The following ultimate constituents
of albumin, fibrin, and casein show a successive increase of
oxygen as we pass from the former to the latter, and a de-
crease of sulphur and phosphorus. This is the result of the
oxidation to which reference will be frequently made as we
proceed with the argument :
Albumin.
Fibrin.
Casein.
55-46
54-45
54-66
Hydrogen
7-20
7-07
7-15
Nitrogen
16-48
17-21
15-72
18-27
19-35
21-55
2-16
1-59
•92
•43
•33
In the retrogressive metamorphoses the sulphur and
phosphorus are converted into sulphuric and phosphoric
acids. This is the source of those acids which are found in
the urine and perspiration of rheumatic patients. The sul-
phur and phosphorus being thus extracted from the fibrin,
the gases are left to arrange themselves into other forms
known to chemistry as osmazome, creatin, creatinin, uric
acid, and urea. These transformations are the conditions
through which the nitrogenous matters are to pass in order
to be eliminated from the system. These successive forma-
tions, and perhaps others unknown to chemistry, may be
either intra- or extra-vascular — i. e., in the latter case, take
place in the muscles or fibroid tissues, where they act as irri-
tants to which may be ascribed the pain and inflammation
of rheumatism, and the consequent thickening of the tissues
affected and the stiffness of the joints which so commonly
attend this disease.
Another product of fibrinous metamorphosis is a low
form of protein compound capable of being deposited in all,
or nearly all, the tissues of the body, but finds the lungs to
be its favored site, and is known to the pathologist as tuber-
cle. In support of the view that tubercle is the product of
the metamorphoses of nitrogenous matter, whether originat-
ing from fibrinous blastema or from fibrin itself, Rokitansky
says: "Many blastemata, distinguished for their coagula-
bility, do not rise above the lowest grade of form develop-
ment, and not alone do they stop at the grade marked out
by the process of coagulation, but their ulterior tendency is
to liquefy. An example is afforded in tubercle." . . .
" Chemically considered, all blastemata for pathological new
growths are protein compounds, for the most part in various
degrees of oxidation." Again : " In the first place, the
ground-work of rapidly solidifying tubercle blastema is,
without the least doubt, fibrin." And Dr. Glover, in his
analysis as quoted by Dr. Aitken, says that very little dif-
ference in ultimate composition has yet been detected be-
tween recent tubercle and the other so-called compounds of
protein.
Upon the hypothesis that tubercle finds its origin in
fibrin, an intimate relation between the fibrin-crasis and
tuberculosis 'must necessarily subsist ; consequently, an in-
quiry into some facts and circumstances attending the fibrin-
crasis may be made with a hope of finding not only the
cause of tubercle, but also a remedy for the evil. And, in
addition to these, we may find some interesting facts which
pertain alike to tuberculosis and rheumatism. With this
threefold purpose in view, we will consider the two diseases
in their correlation with hyperinosis, as follows :
1. The two diseases are attended with hyperinosis. ;
2. The two diseases have a common origin in the causes
which produce hyperinosis.
3. The two diseases result from retrogressive metamor-
phosis of the fibrin.
4. The two diseases find a common remedy in those
means which correct the hyperinosis.
In regard to the first of these, it is not necessary to
adduce evidence of a fact which is already established.
2. That the two diseases have a common origin in the
causes which produce hyperinosis finds a solution in the
conditions and circumstances which surround those who
are engaged in pursuits that require great muscular exer-
tion. Among these may be recorded " tumblers," men who
perform in the circus-ring, mechanics, miners, and opera-
tives in mills. Now, it is worthy of note that these classes,
as a rule, enjoy an immunity from tubercle while most
actively engaged in their business ; but when their health
declines, so that they can not labor so hard, or when, from
any cause, they cease to labor in any degree, or change
their manner of life from active to sedentary habits, tubercle
finds its most favored opportunity of presenting itself. We
find a most beautiful and convincing illustration of this
184
DIX: ALCOHOL, RHEUMATISM, AND PHTHISIS.
[N. Y. Med, Joob.,
principle as it obtains among wild animals when in cap"
tivity. These animals, when in their native lands and en"
joying a mode of life that is natural to them, are compara
tively exempt from tubercle; but when in captivity, they
are prone to this disease. " The Austrian runners," Dr
Aitken says, " are another class who are instances of break"
ing down by over-exertion in running at ages unsuited for
their strength. They seldom live beyond three or four
years, and gradually die of consumption " (" Remains of
Mrs. Trench," p. 72). This same thing occurred in the
person of a little girl, a near relative of the writer. Her
father conceived the idea that his daughter should be ac~
tively exercised in the open air, and to this end he would
take his daughter on long and fatiguing walks. The result of
this vigorous exercise was phthisis pulmonalis. In this case
there had not been a trace of tubercle on the mother's side
(and the ancestry was known for several generations), and
none, so far as the writer has learned, on the father's side.
This case may be safely placed to the credit side of muscu-
lar exertion.
Another evidence that fibrin is intimately associated
with tubercle is found in the well-known fact that mothers
afflicted with phthisis pulmonalis enjoy an abatement of the
disease during pregnancy ; but after childbirth the disease
assumes a fresh impetus, and the mother finds in the grave
an early termination of her sufferings. This temporary
relief is obtained by a consumption of the fibrin in foetal
construction. And, again, there are three periods of life
most favorable to tubercle : First, in early life, including
intra-uterine existence, when the vital forces are exerting
themselves in fibrin construction ; second, when the body
has about obtained its growth and there is a surplus of
fibrin; third, in the declining periods of life, when there is
an absorption of fibrinous waste. Dr. Bennett places " hard
work" among the causes of tubercle. In confirmation of
this, all of the five thousand six hundred and twenty-seven
persons affected with phthisis, as tabulated by Dr. Aitken,
were working people.
" On the other side," says Rokitansky, " the pre-eminent
immunity afforded by exquisite venosity and cyanosis,
against fibrin-erases, more especially the higher (croupous)
grades, and most particularly against tuberculous crasis —
taking, we say, all these circumstances duly into account, we
are forced on to the momentous conclusion that arterial ity —
that is, the arterial development of fibrin — pre-eminently con-
stitutes the cardinal character of tuberculosis.'1'' He says
again : " There exists undeniably a habit, expressed in a
delicate construction of the soft parts, in imperfect develop-
ment of the muscular, with preponderance of the vascular,
system, and in a so-called phthisical build of the thorax*
commonly deemed ominous of pulmonary tubercle. It is
essential, however, that this build should not, according to
the vulgar notion, be imputed to the smallness of the lungs
within a seemingly insufficient thorax, but rather to very
voluminous lungs within a thorax the obvious narrowness
of which, in its antero-posterior diameter, is amply compen-
sated for by its length, with a relatively small abdominal
cavity and small abdominal viscera."
Active muscular exertion induces an expansion of the
breathing capacity, increased arterial circulation, and, con-
sequently, increased arterial development of fibrin. This
increase of fibrin finds a reservoir in the developed muscles,
thus far filling the conditions most favorable to tubercle,
which will obtain when there is a cessation, in some degree,
from muscular exertion. This will cause a quantity of
fibrin, when in the process of retrogressive metamorphosis,
to be thrown into the blood-mass, and supplies the tuber-
cular pabulum. This pabulum is supplied to the blood by
whatever circumstance may cause the fibroid tissues to break
down ; and, as this obtains in inflammatory fevers and wast-
ing disease, we have tubercle as a consequence.
In the habit, as just quoted, the delicate construction of
the soft parts seems to be due to the accompanying prepon-
derance of the vascular system, which retains, as it were, the
fibrin, and thus prevents its assimilation, and the develop-
ment of those tissues into which fibrin enters so largely ;
hence, "a delicate construction of the soft parts" ; and the
fibrin, instead of performing its proper function in the con-
struction of tissue, is converted into tubercular matter.
3. The retrogressive metamorphosis of fibrin into tuber-
cle, as well as in rheumatism, consists in oxidation. And
the first results of this oxidation is the conversion of the
sulphur and phosphorus of the fibrin into their respective
acids. In this we have a sufficient explanation of two con-
ditions which usually attend patients with incipient phthisis
— viz., first, an acid co»dition of the system, especially of
the digestive organs ; second, an aversion to fatty ingesta.
The latter is due to the fluids which emulsify the fats prepa-
ratory for digestion being rendered neutral or even becom-
ing acidified instead of retaining their normal alkalinity.
When the fibrin is freed of its sulphur and phosphorus, it
must undergo further oxidation in order to become tuber-
culous matter. In this transmission the caseous matter
assumes a taint just as fruit does when undergoing oxidation
or rotting ; and, as this taint is capable of being communi-
cated to other and yet healthy fruit, so this tubercular taint
is capable of being communicated to other and yet healthy
fibrin.
This taint may find its origin in an individual from one
of the following four causes : First, it may be transmitted
from parent to offspring ; this obtains when tubercle ap-
pears in the foetus or in infancy ; second, in cases of exces-
sive lung capacity, and a preponderance of the arterial over
the venous system — these conditions of the organism may
be congenital, or acquired by following such pursuits as will
increase the lung capacity ; third, by local oxidation, as
when phthisis pulmonalis follows fistula in ano, or tubercu-
lar inflammation of a joint — these form foci from whence
tubercle is disseminated to other and distant parts of the
body ; fourth, by a healthy person inhaling the breath of a
consumptive patient. This obtains by constant and inti-
mate association of a healthy person with a consumptive
patient.
In the latter case, it is reasonable to presume that the
taint is carried by the micrococci of Koch. These micro-
organisms may be considered as a product, as mildew or
fungus is the result of organic matter being exposed to oxi"
dation.
August 15, 1885.J
BOOK NOTICES.
185
4. The two diseases find a common remedy in those
means which correct the hyperinosis. This proposition
necessarily involves the treatment of the two diseases. As
much of that which can be said of the one is alike applica-
ble to tbe other, we will, for the present, speak of tubercle;
and the treatment^ may be considered under two headings,
viz. :
1. Preventive.
2. Curative.
In considering the preventive means, we are met on the
threshold with a very pertinent question — viz., How are we
to prevent' hereditary phthisis ? In answer to this, only a
like pertinent response can be made, which is : If the par-
ents can not be cured, then forbid them bearing children.
Aside from an inherited taint, an organism which is
conducive to tubercle may be congenital — viz., large lung
capacity and arterial predominance over the venous system.
A person with such an organic construction should strenu-
ously avoid vigorous exercise, and those circumstances and
pursuits which occasion deep and prolonged inspirations.
His diet should be of the carbohydrates ; and as these be-
long, almost without exception, to the vegetable kingdom,
and constitute the non-nitrogenous food, his diet should be
vegetarian and not of meat. He should avoid the in-
halation of an atmosphere laden with dust of any kind,
as well as the breath of other people, inasmuch as this con-
tains highly oxidized matter from the lungs. Such un-
wholesome atmospheres are found in crowded sleeping
apartments, schools, and places where many people are as-
sembled. But all the means of avoiding the inhalation of
large quantities of air should be adopted. To this end the
corset or moderate lacing is beneficial if not carried to such
an extent as will interfere with the stomach and liver in the
performance of their functions. Another and a most effi-
cient means of lessening the amount of air taken into the
lungs is to live in a warm climate. This constitutes the sole
benefit that consumptives derive by going to Florida or
other warm climates. There the atmosphere is rarefied by.
the higher temperature, so that less air is taken into the
lungs at each inspiration. There are also two other circum-
stances to be met with which are important to the consump-
tive ; viz., first, the higher temperature produces a lassitude
which prevents so much exercise being taken — consequently
less breathing ; second, the diet consists more of fruits and
vegetables and less of meats than in the more northern
States ; thus the fibrin is diminished. In this we find an
ample solution of the problem involved in the rheumatic
and consumptive patients declaring themselves greatly bene-
fited by a winter spent in the Southern climes.
2. The curative treatment will involve a continuation of
the preventive means as just enumerated. The next urgent
matter to be considered is the acid state of the system
which usually accompanies tuberculosis. A most efficient
means of meeting this is the administration of one drachm
of saccharated lime-water, and one grain each of hypophos-
phite of lime and of sodium, to be taken half an hour before
each meal, dissolved in as much water as the patient can con-
veniently drink. The next important step is the correction
of the taint. The means best adapted to this end lie in the
use of the carbohydrates. The most prominent are alcohol
and cod-liver oil. In order to obtain the greatest benefit
from these, it is necessary to observe the condition under
which they are administered. If the system is not freed
from its acid condition, the oil can not be digested. And
the object of administering the alcohol and oil would be
defeated by advising the patient to take more exercise than
is actually necessary, as it would be a great folly to give
these agents to consume the oxygen and then direct the
patient to inhale more oxygen by taking excessive exercise.
In exercising, the patient should be as passive as possible —
as in riding in a carriage or light horseback exercise. The
use of alcohol and the oil will prove more efficient where
the patient is strictly kept upon a pure vegetable diet.
These agents act in preserving the fibrin from oxidizing in
a manner similar to preserving fruit by keeping it free
from the influence of oxygen ; i. e., by combining with the
oxygen instead of the fibrin.
The parallelism of rheumatism and tubercle subsists in
the hyperinosis and oxidation, and ceases with the latter.
In rheumatism this consists in the oxidation extending only
so far as the conversion of the phosphorus and sulphur into
their respective acids ; and not so far as to change or to
rearrange the remaining elements of the fibrin into the form
of caseous matter, but leaves it to pursue a more normal
course in its metamorphic processes.
As the treatment of the two diseases in detail does not
fall within the scope of this paper, it only remains to ob-
serve that, inasmuch as oil, alcohol, or a non-nitrogenous
diet lessens the quantity of fibrin in the blood, the forego-
ing sufficiently demonstrates the proposition that drinking
men, under ordinary circumstances, enjoy an immunity
from rheumatism and tubercle.
§crok Notices.
Manual of General Medicinal Technology, including Prescrip-
tion-Writing. By Edward Curtis, A. M., M. D., Professor
of Materia Medica and Therapeutics, College of Physicians
and Surgeons, etc. New York : William Wood & Co., 1883.
32mo, pp. viii-234.
Dr. Curtis has made a very systematic and useful little hook
and a very accurate one. The information it contains should
be in every work on materia medica and therapeutics, and yet
usually the subjects handled are very scantily treated of in such
books. The technicalities of prescription-writing are discussed
at considerable length. The naming of medicines, their forms,
and the determination of the quantities of medicine to be used,
are all carefully discussed. The methods of medication and dos-
age receive appropriate treatment. The questions of compati-
bilities of drugs, both chemically and physiologically, are also
discussed. The book is for students, and is calculated as a re-
minder. The United States Pharmacopoeia is followed, and the
metric system is given a place.
Studenfs Manual of Electro-therapei/ties. By K. W, Amidon,
M. D., etc. Now York : G. P. Putnam's Sons, 1884. Pp.
v-93.
Dr. Amidon's book contains a very clear and straightforward
account of the physical principles which underly electro-thera-
186
LEADING ARTICLES.
[N. Y. Med. Joub.,
peutics. Indeed, we do not recollect having anywhere seen
condensed in so concise and yet satisfactory a shape the laws
governing electrical currents, and the facts regarding the physio
logical and pathological reactions of the human organism to
electricity. The electro-therapeutical deductions from these
facts are given very briefly and are mainly drawn from the
author's personal experience, and are hence perhaps more valu-
able— certainly more authoritative— than if taken from hearsay
or at second-hand.
The book is well adapted to its purpose — namely, to supply
to the student of practical electro-therapeutics some elementary
notions upon the subject ; enough to enable him to employ a
battery intelligently and understand the reactions which are
involved.
Chemistry: Inorganic and Organic, with Experiments. By
Charles Loudon Bloxam, Professor of Chemistry in King's
College, London, etc. From the fifth and revised English
edition. With two hundred and ninety-two illustrations.
Philadelphia : Henry C. Lea's Son & Co., 1883. Pp. xxvii-
33 to 738, inclusive.
This, the fifth, edition of Bloxam's well-known treatise has
been subjected to careful revision, and the sections occupied
with the principles and theory or science of chemistry have been
brought " into harmony with modern views." The fundamental
conceptions of chemistry relating to the constitution and prop-
erties of matter are amply and clearly, yet withal briefly, pre
sented to the student in their most developed forms. Still, we
miss any consideration of the import and relations of heat to
molecular exchange, a growth of modern physics which promises
to absorb the entire philosophy of chemical science.
As a practical treatise, responding to the demands of the
medical student and working chemist, the present work will
make secure the place won by previous editions.
BOOKS AND PAMPHLETS RECEIVED.
Outlines of Psychology, with bpecial Reference to the The-
ory of Education. A Text-book for Colleges. By James Sully,
M. A., Examiner for the Moral Sciences Tripos in the University
of Cambridge, etc. New York : D. Appleton & Co., 1885. Pp.
xxiv-711.
A Text-book of Physiology. By M. Foster, M. A., M. J)., F.
R. S., etc. Third American, from the Fourth and Revised Eng-
lish Edition. By Edward T. Reichert, M. D., Demonstrator of
Experimental Physiology in the University of Pennsylvania.
"With Two hundred and seventy-one Illustrations. Philadel-
phia: Lea Brothers & Co., 1885. Pp. 911.
Poisons : their Effects and Detection. A Manual for the
Use of Analytical Chemists and Experts. With an Introduc-
tory Essay on the Growth of Modern Toxicology. By Alex-
ander Wynter Blyth, M. R. C. S., F. C. S., etc. With Tables
and Illustrations. Volume I. New York: William Wood &
Co., 1885. Pp. xxxiv-333.
Tracheotomy in Laryngeal Diphtheria; After-treatment and
Complications. By Robert William Parker, Surgeon to the East
London Hospital for Children, etc. Second Edition, Revised and
Considerably Enlarged. London : H. K. Lewis, 1885. Pp xvi-
124.
Medical Thoughts of Shakespeare. By B. Rush Field, M. D.,
Member of the Shakespeare Society of New York. Second Edi-
tion, Revised and Enlarged. Easton, Pa. : Andrews & Clifton
1885. Pp. 86.
Lectures on Pulmonary Phthisis. By Ernest L. Shurly,
M. D., etc. [Reprinted from the " Medical Age."J •
Minutes of the Thirty-second Annual Session of the Medical
Society of North Carolina.
NEW YORK MEDICAL JOURNAL,
Published by
D. Appleton & Co.
A Weekly Review of Medicine.
Edited by
Prank P. Fobteb, M. D.
NEW YORK, SATURDAY, AUGUST 15, 1885.
FERRAN'S FIASCO.
It would be wrong to jump to the conclusion, from the
utter collapse of Dr. Ferran's vaunted procedure in the prevent-
ive inoculation of cholera, that inoculation may not yet be so
carried out as to answer the purpose. But the tendency is a
natural one to settle down into the stagnation of such a conclu-
sion whenever a grand scheme of any sort is proved to be a
bubble, and especially when, as in this instance, its promoter
takes a position where he shows himself rather a seeker after
pecuniary reward than a devotee of either science or humanity.
It is of little consequence to the world when a person who has
posed for a time as a great discoverer and a benefactor of the
race drops to the level of a charlatan, except that the occur-
rence tends to create a disinclination on the part of competent
and well-balanced men to enter upon a path which, whatever
promise it might otherwise have seemed to hold out, has been
in a certain sense defiled. To be sure, this feeling of aversion
is always outgrown in time, but results that, but for its exist-
ence, would in all probability have been arrived at with rapid-
ity are postponed many years, to the great detriment of prog-
ress.
If failure had been all that was to be chronicled of Dr.
Ferran's process, that in itself would not have brought him
down to the station he now occupies in the eyes of the profes-
sion; he would simply have been set down as one who had
generalized from insufficient data — a proceeding not unheard of
in men who have nevertheless continued to enjoy the respect
of their fellow-laborers, and even done subsequent solid service
to science. Nor would his reserve — to use no harsher term —
as to the details of his laboratory work, if indeed he has done
anything worthy of the name, have aroused any special dis-
trust, provided it had gone before his bold announcements. He
might have been as silent as the tomb, and sported his oak like
a miser, so long as his project was in that part of the experi-
mental stage which ought unquestionably to have been worked
out to the last detail before inoculations of human beings were
resorted to as the final test : and it could not reasonably have
beeu objected that he was straying from the legitimate course.
But, when he appeared, so to speak, vaunting a perfected pro-
cess with one breath and smothering investigation with the
next, the weakness of his position was all but demonstrated.
It was natural, too, that he should look forward to a pecu-
niary reward when he had satisfied the world of his success.
And under such circumstances, beyond all question, the recom-
pense would have been forthcoming, and it would have been a
handsome one. Jenner not only accepted, but took means to
obtain, a substantial recognition of his great services to mankind,
August 15, 1885.]
MINOR PARAGRAPHS.
187
And the fact has never dimmed the luster of his fame. His
countrymen were glad and proud to afford him a tithe of the
money that his discovery had saved, to say nothing of its other
beneficent consequences, although the whole world gained by it
as well as themselves. But Jenner worked patiently for years
before he even announced his conclusions, and he countenanced
no movement looking to a pecuniary recompense until all civil-
ized communities had had the soundness of his doctrine and
the utility of his practice demonstrated to them over and over
again and on a large scale.
As matters stand, however, a practice abundantly shown to
be well-nigh if not altogether useless, secrecy as to details — not
for purposes of undisturbed study, but apparently only for mys-
tification— and a hand held out after the manner of Artemus
Ward's showman when be said to a would-be dead-head : "You
can pay without going in, but you can't go in without paying";
all these features make the contrast sharp between Dr. Ferran's
case and that of any one of the world's few great discoverers.
Let us hope that this very pointedness of the contrast may to a
certain degree rob his fiasco of the retarding influence it might
otherwise have had on researches in the preventive inoculation
of cholera.
MINOR PARAGRAPHS.
ARTIFICIAL VIABILITY.
Perhaps this term may properly be applied to the results
which seem capable of achievement by following certain devices
that have been brought forward by the Paris obstetrician, M.
Tarnier. Until lately, it was the practical difficulty of maintain-
ing them at a uniform temperature of the required degree that
made the survival of children born on the bare attainment of
viability so decidedly improbable. M. Tarnier's success in doing
away with this obstacle, by means of the couveuse, is well known
to our readers. But this is not all. At a recent meeting of the
Academie de medecine, as we learn from the " Progres medical,"
M. Tarnier insisted upon the necessity of forced feeding (gavage).
Through a urethral catheter passed into the stomach, and pro-
vided with a glass funnel at its free end, a nutritive liquid is to
be poured, preferably human milk. In the case of very young
infants, two drachms of milk are injected every hour, and, after
a time, the breast is given in alternation with these injections.
The cautions are mentioned that the catheter should be with-
drawn rapidly after the milk has reached the stomach, and that
care should be taken not to throw in too much at any one time.
By resorting to these expedients, it is thought, children born so
early as the sixth month may be reared.
A FRENCH VIEW OF THE AMERICAN TRADE
PROPENSITY.
" Lyon medical " has noticed an advertisement of an Ameri-
can device termed a " menstrual receptacle," and, under the
caption "On s'arretera 1'industrialisme americain?" remarks
that the advertiser has devised a little cup which, embracing
the cervix uteri, is intended to receive the catamenial dew with-
out the loss of a drop. The dimensions of the shank which
supports the cup give rise to reflections, says our contemporary,
the first of which is, that it is surely impossible to push prog-
ress farther — or deeper.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Health Department for the following
statement of cases and deaths reported during the two weeks
ending August 11, 1885 :
DISEASES.
Week ending Aug. 4.
Week ending Aug. 11.
Cases.
Deaths.
Cases.
Deaths.
27
5
14
4
23
4
8
2
Cerebro-spinal meningitis. . . .
2
2
2
1
21
4
16
2
33
17
20
14
2
0
1
0
The Health of Foreign Cities.— We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office since
the date of the last bulletin, August 4th. Acapulco, Mexico. —
For the week ending July 19th: Free from epidemic diseases.
Cape Eaytien, Hayti. — For the week ending July 25th : Free
from epidemic diseases. Cardenas, Cuba, and Laguayra, Vene-
zuela.— For the week ending July 25th : Free from epidemic
diseases. CaUao, Peru. — For the week ending July 4th : One
death from yellow fever and one from small-pox. Fever re-
ported as declining in the town. Small-pox prevailing very
generally among the lower classes. London, England. — For
the week ending July 20th : 118 cases of small-pox admitted to
hospital during the week; 15 deaths reported. Total number
of cases in hospital at the end of the week, 7b2 ; deaths from
diarrhoea and dysentery, 210, and from simple cholera, 4. Paris,
France. — For the week ending July 25th : No cholera or small-
pox reported. Nice, France. — For the two weeks ending July
15th : Free from small-pox and cholera. Barcelona, Spain. —
By cable, August 4th, the consul reports cholera present, but
not officially declared. Denia, Spain. — July 28th : Cholera offi-
cially declared ; there are from 3 to 6 deaths daily. Gibraltar,
Spain. — August 9th: 1 death from cholera at the civil hospital.
Malaga, Spain. — August 7th, the consul reported 4 cases of
cholera; on the 11th the civil authorities announced that the
cases reported on the 7th were not cholera. Genoa, Italy. —
For the week ending July 12th: Free from epidemic diseases.
Venice, Italy. — For the week ending July 11th : 2 deaths from
small-pox. St. Petersburg, Russia. — For the week ending July
18th: 3 deaths from small-pox. The presence of yellow fever
at Vera Cruz, Mexico, has been announced by telegram from
the consul, but no further information has yet been received.
The Mount Sinai Hospital Training-School.— We learn
that Miss P. B. Washburne, the principal of the school, has re-
signed, and that Miss A. F. Jones, who lately resigned the posi-
tion of superintendent of nurses at the Charleston, S. C, City
Hospital, is to succeed her. Both ladies are graduates of the
New York Hospital Training- School.
Medical Department of Yale College.— It is reported that
Dr. F. E. Beckwith has resigned the chair of Obstetrics and Dis-
eases of Women and Children.
Carney Hospital, South Boston, Mass.— Dr. William A.
Dunn has been appointed visiting surgeon, and Dr. G. II. Monks
and Dr. H. W. Cusbing have been appointed surgeons, to the
out-patient department.
The Illinois Register of Physicians and Midwives.— The
Illinois State Board of Health gives notice that it is now en-
gaged in revising the " Register," and that it will regard any
notification of changes, omissions, or errors as a favor. Corre-
188
PROCEEDINGS OF SOCIETIES.
[N. Y. Mbd. Jode.,
spondents should address : " The Secretary of the State Board
of Health, Springfield, 111."
The Death of Dr. George A. Bates, of Worcester, Mass.,
occurred suddenly on Saturday, August 8th, in his sixty-fifth
year. He was graduated from Harvard Medical School in 1844,
and the greater portion of his professional life was spent in "Wor-
cester. He was a member of the Massachusetts Medical Society.
The Death of Dr. Joseph R. Draper, of South Boston,
Mass., took place on Wednesday, August 5th, in his fifty-fifth
year. He was a native of Wayland, Mass., and was graduated
from Berkshire Medical School in 1863. He was a member of
the Suffolk District, and of the Massachusetts Medical Societies.
The Death of Dr. William Wood, of East Windsor, Conn.,
took place on Sunday, August 9th, at the age of sixty-three. He
was a native of Waterbury, Conn., and was graduated from the
Medical Department of the University of the City of New York
in 1847. He was a member of the Hartford County, Conn.,
Medical Society, the Lyceum of Natural History of Williams
College, and a corresponding member of the Nuttall Ornitho-
logical Club of Cambridge, Mass., and was a recognized author-
ity in ornithology.
The Death of Dr. Thomas B. Jewett, of Birmingham,
Conn., took place on Sunday, August 9th, in his thirty-seventh
year. He was a son of the late Dr. Pliny A. Jewett, of New
Haven, and was graduated from the Medical Department of
Yale College in 1879.
The Death of Professor Milne Edwards is announced in
the " Gazette hebdomadaire de medecine et de chirurgie." He
had reached the age of eighty-five years, and had been a teacher
for many years. At the time of his death he was a member of
the Academie des sciences and of the Academie de medecine,
honorary dean of and professor of comparative physiology in
the Faculte des sciences, and professor at the Museum of Natural
History. Early in his career he made numerous contributions
to practical medicine, but the greater part of his life was de-
voted to physiology.
Army Intelligence.— Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from August 2, 1885, to August 7, 1885:
Brown, J. M., Surgeon ; Ewex, Clarence, and Taylor, A. W.,
Assistant Surgeons. Ordered to rejoin their proper stations
in the Department of the Platte. G. O. 7, Division of the
Missouri, August 1, 1885.
Edie, G. L., and Black, C. S., Assistant Surgeons. Ordered to
rejoin their proper stations in the Department of Texas. G.
O. 7, Division of the Missouri, August 1, 1885.
Powell, J. L., Captain and Assistant Surgeon. Assigned to
temporary duty at Fort Leavenworth, Kansas. S. O. 110,
Department of the Missouri, July 30, 1885.
Dietz, William D., First Lieutenant and Assistant Surgeon.
Ordered from Fort Selden to Fort Stanton, New Mexico.
S. O. Ill, Department of the Missouri, July 31, 1885.
Society Meetings for the Coming Week :
Monday, August 17th : Hartford City, Conn., Medical Associa-
tion ; Chicago Medical Society.
Tuesday. August 18th : Medical Society of the County of Kings,
N. Y. ; Ogdensburg, N. Y„ Medical Association.
"Wednesday, August 19th: New Jersey Academy of Medicine
(Newark).
Thursday, August 20th: New Bedford, Mass., Society for Medi-
cal Improvement (private).
NEW YORK ACADEMY OF MEDICINE.
Meeting of May 21, 1885.
The President, Dr. A. Jacobi, iu the Chair.
Observations on the Treatment, Medical and Surgical,
of Acute Peritonitis.— Dr. T. II. Bobohabd read a paper on
this subject. [See p. 169.]
Dr. A. L. Loomis did not believe in idiopathic peritonitis;
for five or six years he had searched diligently at autopsies for
a case in which no local or constitutional cause of the peritonitis
could be recognized, but he had found none. As the author
had stated, we could group all cases under three heads — those in
which the cause was constitutional and dependent upon blood
poisoning, those arising from extension of inflammation from
neighboring parts, and those dependent upon perforation or
rupture of some form. He had yet to see a case of peritonitis
end in recovery in which there had been unmistakably an escape
of intestinal gases into the peritoneal cavity. He recognized
the escape of the intestinal contents into the peritoneal cavity
as one of the most fatal of accidents. It was not always possi-
ble to determine just what part of the gut was involved, even
in cases in which the symptoms were localized, for previous
adhesions, etc., might have caused a displacement of the several
portions of the intestine. But, if the commencing point of peri-
toneal inflammation could be determined exactly, he would
most heartily indorse all that had been said in favor of lapa-
rotomy. He had seen more than one such case. Where there
was perforation of the vermiform appendix there often existed
localized peritonitis, with fixed pam, increased on firm pressure,
arrest of abdominal respiration, and feebleness of heart power
which did not correspond to the amount of pain or the apparent
gravity of the disease. When such symptoms came on rapidly
or suddenly, he thought we were justified in resorting to sur-
gery, or, if the symptoms did not yet point positively to per-
foration, the physician should stand by his patient prepared to
perform the operation when the first signs of perforation should
appear. He bad on several occasions pointed out to surgeons
the indications for the use of the knife in acute peritonitis. Ex-
perience had shown that the peritonaeum was not such a danger-
ous membrane to invade as it had formerly been regarded. If,
however, general peritonitis had developed, with shock and
collapse, the pulse at 160, and the respirations altogether tho-
racic, an operation offered but little chance of success. It was
in the early stage that the operation should be done, to give the
best chance of recovery. He believed thoroughly in the opium
treatment of peritonitis, but with restrictions, such as had been
pointed out in the paper. For a long time he had guarded his
first doses of opium with atropine ; later on in the disease it
was not so necessary to combine atropine with the opium.
Dr. R. F. Weir thought that during the past ten or fifteen
years surgeons had taken a long stride in advance in the treat-
ment of diseases and injuries of the abdomen, especially the lat-
ter. Dr. Loomis, he thought, had struck the key-note when he
stated that there was no such thing as idiopathic peritonitis.
In no case of peritonitis should the patient be allowed to die
without receiving the benefit of an exploratory operation. He
agreed with Treeves that there was no mesocolon which led to
connective tissue behind the peritonaeum; perforations al way-
took place inside the peritoneal cavity. He called attention to
the importance of earlier interference in so-called perityphlitic
abscess ; surgeons should not wait until they were able to with-
draw pus with the aspirator-needle before cutting down and
August 15, 1885.]
PROCEEDINGS OF SOCIETIES.
189
establishing drainage. Tn traumatic cases it was difficult to de-
termine whether the patient was simply in a state of collapse,
whether there was escape of the intestinal contents, or whether
there was hemorrhage. But the comparative safety of explora-
tory incision of the abdominal cavity justified us in such cases
in opening the peritonaeum. He referred to the success of two
operations under such circumstances, one being performed by
Mikulicz and the other by Kocher. He was entirely in accord
with the author of the paper as to the importance of an early
operation.
The President said it was a question with general practi-
tioners whether in every case of perityphlitis an early operation
should be resorted to. He believed that we were not all fully
prepared to operate at once, even though the diagnosis might
be satisfactorily made, and for the reason that in a large num-
ber of cases the local inflammation did not extend. We knew
of recoveries, too, in cases in which a perityphlitis had become
a general peritonitis. For the general practitioner, it certainly
was a responsible position to decide the question whether or
not an operation should be done at once, or whether we should
wait for some time. He had met with just such a case within
the last two weeks, that of a boy fifteen years of age who gave
a history of perityphlitis — sudden pain, local swelling in the
right inguinal region, some dullness on percussion, slight eleva-
tion of the thigh, a moderate amount of fever, and absence of
collapse. In such a case, then, the question would be raised,
Should an operation be performed at once ? The patient was
given morphine with atropine, and they applied ice, ice, ice!
The peritonitis became general, but the symptoms were not
urgent; the temperature rose above 103° only once; there was
pain over the abdomen, with thoracic respiration. He hesitated
to recommend an operation, because the general condition of
the patient seemed to justify a little more waiting. If in such
a case death should occur, perhaps the physician might be re-
proached with not having proposed an operation. He heartily
agreed with the statement that there were hardly any cases of
idiopathic peritonitis. He was not prepared to say, even after
hearing this paper and the discussion, that he would at once
propose laparotomy in the class of cases mentioned, but he
would propose it if peritonitis had set in suddenly after an
attack of perityphlitis, and extended very fast. Dr. Loomis had
said, Operate when the first sign of perforation makes its appear-
ance ; but perforation was frequently the first thing which oc-
curred.
Dr. Loomis thought he had said that the surgeon should be
prepared to operate in all of these cases as soon as the evidences
of perforation became known. He would beg to question the
statement that perforation was the beginning of a perityphlitis.
He mentioned a case in which he saw the patient on a Thurs-
day, when there were localized symptoms in the right iliac re-
gion, not severe, but the facies pointed to some serious trouble^
On Friday the patient felt well and got up, but on Saturday
there was sudden collapse, and death occurred with general peri-
tonitis. Autopsy showed lymph about the local trouble, of two
or three days' formation, and evidence of subsequent perfora-
tion and general peritonitis. Had an operation been done at
first, the patient might have recovered.
Dr. Weir remarked that in speaking of an early operation
he did not mean that it was necessary to resort to laparotomy,
but to the ordinary operation for perityphlitis, with the inser-
tion of a drainage-tube.
Dr. Loomis had stated at the beginning of his remarks that
there was no cause of peritonitis which was so fatal as the es-
cape of the intestinal gases into the peritoneal cavity. He could
understand how the vermiform appendix might be plugged at
its opening into the intestine, and ulcerations occur farther on
which might set up an inflammation in the connective tissue,
give rise to hardening, etc., and recovery finally take place ; but,
when the ulceration was situated near enough to the intestine
to cause an escape of the intestinal gases, he could not see how
it would be possible for the patient to escape acute general peri-
tonitis.
Dr. Burchard, in closing the discussion, said he had seen six
cases of perityphlitis attended by perforation, in live of which
he made a post-mortem examination and verified the diagnosis.
It was a peculiar fact in these cases, and was commonly true,
as had been pointed out in the discussion, that prior to the per-
foration which caused death there had been one or more attacks
of perityphlitis, and that he considered a very strong diagnostic
mark. If we found a patient in complete or partial collapse
who had had preceding perityphlitis, he thought we were jus-
tified in concluding that there was perforation, and particularly
if there had been previous constipation and the patient had been
taking an active purge. If there was but very little collapse, he
thought we were justified in concluding that, if there was perfo-
ration at all, it was so minute that it could not be diagnosti-
cated. If the collapse was profound, as it was in most cases,
and developed rapidly, we were justified in inferring that there
was perforation.
PATHOLOGICAL SOCIETY OF PHILADELPHIA.
Meeting of June 11, 1885.
The President, Dr. E. O. Shakespeare, in the Chair.
The Relative Malignancy of Different Forms of Sar-
coma.— Dr. H. R. Whaeton presented a large tumor which had
been removed from the posterior portion of the thigh of a pa-
tient in the University Hospital, under the care of Dr. Ashhurst.
The patient was a man, thirty-two years old, who, some eight
years ago, had first noticed a small tumor of the posterior por-
tion of the left thigh, about six inches above the popliteal
region. Since that time it had gradually increased in size, and
at the time of his admission it was larger than a man's head
and oblong in shape. Its growth had been accompanied by
paroxysmal attacks of severe pain. The patient did not remem-
ber any injury of the part. The tumor was enucleated without
difficulty, laying bare about six inches of the sciatic nerve,
which was directly in contact with the capsule of the tumor,
over which also portions of the semi-tendinosus and biceps mus-
cles were stretched. The tumor was found to consist of one
large cavity containing a reddish-browyn fluid, surrounded by a
fibrous wall varying in thickness from an inch to two inches,
and in places presenting numerous points of calcareous degen-
eration. The inner surface of this wall was lined with irregu-
lar flocculent masses. Microscopical examination showed the
growth to be a spindle-celled sarcoma with scattered areas of
calcareous degeneration. The chief points of interest in the
case were the large size of the tumor, its slow development, and
the ease with which it was removed without injury to adjacent
structures.
Dr. Tyson thought it would be interesting to determine if
this cyst — which was a typical example of cyst-formation by
softening — had an endothelial lining. He also asked as to the
nature of the liquid contents.
Dr. de Sohweinitz replied that he had been foiled in his
efforts to make satisfactory sections, from lack of time to decal-
cify the growth. He had determined, however, that it was un-
questionably a spindle-celled sarcoma. The contents of the
cyst had been spilled during the operation; they were of a
chocolate color.
Dr. Barton said that at the previous meeting Dr. Nancrede
190
REPORTS ON THE PROGRESS OF MEDICINE.
[N. "Y. Mbd. Jock.,
had shown two growths with a similar clinical history and of
analogous histological characters. It would be interesting to
examine both growths with reference to the state of the walls
of the blood-vessels, as suggested by Dr. Nancrede, to ascertain
if any light could be thrown on the question of the non-malig-
nancy of the so-called recurrent fibroid tumor of Paget.
Dr. Nancrede remarked that at the previous meeting he had
specially called attention to the fact that the so-called recurrent
fibroid of Paget was a small-spindle-celled sarcoma. The posi-
tion which such growths occupied — viz., in the subcutaneous
connective tissue — did not seem to him, as had been suggested
by Dr. Simes, a satisfactory explanation of their non-recurrence.
He was under the impression that a careful study of the histol-
ogy of their vessel-walls would demonstrate that they more
closely resembled those of a fibroid tumor than those of other
sarcomata in not being merely channels through the tissue, di-
rectly or almost directly in contact with the tumor-cells. lie
thought that "recurrent fibroid" was a good clinical term, as
applied to a certain class of sarcomata, since other tumors much
resembling them in histological character pursued a far different
course.
Dr. Tyson said that he had early made a study of the growth
first known as the fibro-plastic tumor of Lebert, and afterward
named by Paget recurrent fibroid, but now correctly included
among the sarcomata of Virchow. He thought that the ex-
planation of its non-malignancy was to he found in the fact that
the physiology of sarcomata varied greatly in this respect, some
being scarcely more malignant than certain fibromata, while
others vied with the worst cancers in this characteristic. The
former were represented by the hardest of the sarcomata, which,
again, were the small-spindle-celled growths and might be said
to be the type of the recurrent fibroid of Paget. He agreed
with Dr. Nancrede that the term was a good one clinically,
designating a small-spindle-celled sarcoma recurring in loco, but
seldom by metastasis.
Dr. Formad said that no true tumor ever had arteries or
veins; their blood-vessels were merely blood-channels without
muscular walls, even in fatty tumors. The cancers were an
exception to this; they had true blood-vessels and nerves, and
hence were painful.
Dr. Nancrede replied that, as Dr. Formad's statements were
totally at variance with those of all reliable observers, he was
not prepared to accept them at present, and still thought that
careful study of the histology of the vessel-walls in the various
sarcomata might reveal something of practical interest.
Dr. Formad said that, to him, the relative non -malignancy
of these growths was plain ; spindle cells could never move from
their position, especially if the blood-vessels were small. The
small-round-celled sarcomata had small cells and were more
vascular ; hence they were very malignant by metastasis. Giant-
cells never traveled.
The President remarked that the suggestions of Dr. Nan-
crede and Dr. Barton, as to a possible difference in the blood-
vessel walls of sarcomata of differing malignancy, were doubt-
less based upon the well-known fact that these growths became
generalized through the blood-channels. This seemed to him a
matter of interest, and it also raised a point which might be
found of importance, if properly investigated, as explaining the
clinical differences. It was indeed true that the tendency to
malignancy by metastasis was due in large part to the ease with
which cells could be detached from their place, and this had as
much to do with metastasis as the supposed mobility of ele-
ments. As to the condition of the vessel-walls in recurrent
fibroma, he was very sure that, in the primary tumors which
had been diagnosticated, after removal, as pure fibromata with
numerous endothelial cells along the bands of fibrous tissue,
recurrences had shown a change of type to that of perfect sar-
comata; yet the blood-vessels in the first were those of con-
nective tissue, while in the second they had the character of
simple blood-channels.
Dr. Hughes would call attention to a theory of a recent Ger-
man observer, that all sarcomata arose from the endothelia of
blood-vessels. On that supposition it could easily be under-
stood how they became generalized ; these cells set up the same
change in the endothelia wherever they touched them, while
cells derived from other structures had no effect. This distinc-
tion might bo made between sarcomata that remained local and
those that became generalized — that the former arose from
fibrous tissue, and not from endothelium.
Dr. Nancrede was of course perfectly familiar with the fact
that mobility of cells had much to do with malignancy, but he
felt compelled to deny positively, upon the basis of experience,
the so-called fact, so positively asserted by Dr. Formad. that
large-spindle-celled sarcomata never could become generalized,
because their cells, from their form, must " stick " in the vessels.
Some years since he had presented to the society a specimen of
the most malignant growth he had ever had the misfortune to
deal with. (Here he repeated its history.) He thought that
Dr. Formad had examined that specimen at the time, and had
not then dissented from his opinion. He would relate other
instances presented to this society, but further remark was un-
necessary, since all observers except Dr. Formad had repeatedly
called attention to the special malignancy of large-spindle-celled
sarcomata, save in certain situations. He would suggest that
positive statements founded on any one observer's experience
were apt to be delusive.
Specimens from an interesting case of pneumonia in a child,
with extensive consolidation, were shown by Dr. M. H. Fus-
sell, and Dr. G. de Sohweinitz showed two specimens of sar-
coma of the choroid.
Reports on % fjrogwss of gjtefoichw,
OBSTETRICS.
By ANDREW F. CURRIER, M. D.
The Influence of Temperature upon the Life of the Foetus, and
upon the Progress of Gestation. — Dore ("Arch, de tocol.") has made
three series of experiments upon animals bearing upon this subject.
He compares these and their results with similar investigations which
were made by Runge, with whom he disagrees in most respects. His
conclusions are as follows: 1. The first conclusion of Runge can not,
with our present knowledge, be refuted — namely, that the temperature
of the foetus is always higher by some tenths of a degree than that of
the mother even when the latter is above the normal. 2. Xo well-con-
ducted experiment has ever proved that the foetus dies a long time
before the mother. [Presupposing that the mother is in a dying con-
dition, from whatever cause.] When the mothers were opened after
death the foetuses were invariably found dead, but when this operation
was performed before death, even though the mothers were in extremis,
the foetuses were found alive. 3. A temperature of 41 '5° C. is not
always lethal for the foetus. Runge thinks that when maintained at
this point for a few minutes it is necessarily fatal. The author's ex-
periments showed that it might in some cases be continued for two
hours without producing death. 4. A temperature of 43° C, if arrived
at by slow and cautious elevation, may be endured for a short period
without interrupting the pregnancy or affecting the vitality of the
foetus. 5. Excessive elevation of temperature alone is insufficient to
produce abortion or premature parturition. In all of the author's ex-
periments, whether the mother succumbed to the heat or successfully
August 15, 1885.]
REPORTS ON THE PROGRESS OF MEDICINE.
191
resisted it, this proposition was sustained. 6. There is great difference,
even with aninials of the same species, in the normal temperature point
and in the rapidity with which hyperpyrexia is acquired, the same rate
of increase of external heat being observed in all cases.
The Influence of Age upon Labor in Primiparae. — Kleinwachter
(" Ztschr. f. Geburtsh. u. Gynak."), after analyzing the statistics of nine
hundred and twenty primiparous cases, which were recorded at the
Innsbruck clinic, the patients varying in age from sixteen to forty-one
years, draws the following conclusions: 1. As a rule, the greater the
age at which conception occurs for the first time, the older the individ-
ual when menstruation began. 2. The reason of this is to be found,
at any rate in part, in precedent disturbances in the ovulation process.
3. Pain occurring either with the first menstruation, or in a subsequent
one soon after it, among those who begin to menstrute at a period
which is later than the usual one ; likewise irregular menstruation, and
pain during coitus, which renders that act imperfect, are causes which
tend to retard the period when conception first occurs. These factors
are most potent in women of an advanced stage of life, less so in those
who are midway in the child-bearing epoch, and least among very young
women. 4. Pathological conditions which have no immediate relations
with the pregnant state interfere with conception least frequently in
young women, but very commonly in older ones. 5. The pain and an-
noyance attending the pregnant state are most common with very ma-
ture primiparae, and less common with primiparae of the middle than
of the earliest stage. 6. Haemorrhages during pregnancy7 occur most
commonly among the young, least commonly among the old. 7. As to
an increase in the quantity of liquor amnii, age does not seem to be a
determining factor. 8. The duration of labor is most frequently pro-
longed beyond the normal time among old priiniparae. 9. Inexpulsive
and ineffective pains are most common among primipara? of the latest
period. 10. The forceps is most frequently called for with those primi-
parae who are more than twenty-nine years of age. 11. Though the
duration of labor is longer with old primiparae than with young ones,
it does not follow that this is an inevitable and unvarying fact. 12.
(This proposition simply qualifies its predecessor.) 13. The percentage
of mortality in primiparae following forceps operations increases in the
same ratio with the age. 14. The older the primipara, the more likely
is the perinaeum to be torn. 15. The older the primipara, the greater
the probability that post-partum haemorrhage will occur. 16. Increase
of age brings increased predisposition to kidney troubles. 17. The
same rule applies in regard to oedema. 18. The older the primipara,
the less the probability that she will suffer with inflammation of the
breasts, or that she will be able to nurse her child. 19. Old primiparae
are most frequently the subjects of puerperal fever ; least frequently
affected are those who are between twenty and twenty-nine years of age.
20. The same rule holds in regard to puerperal mania. 21. Equally true
is it in regard to morbidity and mortality with reference to puerperal
diseases in general. 22. The same rule obtains in regard to spontaneous
abortions ; the older ones are most frequently the sufferers. 23. Ab-
normal presentations are most frequent with old primiparae. 24. As
to the narrow or deformed pelvis, age has no bearing upon the question.
25. The older the primipara, the greater the probability that the off-
spring will be a boy. 26. The children of old primiparae are apt to be
heavier and longer than those of young ones. 27. The older the primi-
para, the more likely is she to give birth to twins. 28. The same is true
in regard to deformed offspring. 29. Also the rule applies in regard to
the vitality of the offspring.
The Treatment of the Perinaeum in Pregnant and Parturient
Women. — W. A. Duncan (" Lancet ") shows that an operation upon a
ruptured perinaeum is not necessarily an efficient cause of abortion in a
pregnant woman by the narration of a case in which it was performed
upon a woman in the third month of pregnancy. She had already
borne two children, and the perinaeum had been ruptured at each labor.
The rent had been closed after the first accident, but not after the sec-
ond, until the operation was performed by the author nine months after
labor. Four deep wire sutures were used, and a sufficient number of
superficial catgut ones. The operation was entirely successful, preg-
nancy was completed, and no accident occurred at the subsequent labor.
In regard to supporting the perinaeum during labor, the author thinks
that the plan is sometimes a very good one, though accidents will some-
times happen in spite of all precautions. The plan which is recom-
mended is to dilate the perinaeum with the fingers closed in the form of
a cone, and applied carefully when the head has reached the perinaeum.
He also approves of the plan of lateral incisions of a rigid perinaeum,
and thinks that the forceps, properly used, will prevent rather than
encourage perineal rupture, on account of the dilating action of the
blades. The supporting power of the perinaeum to the pelvic organs is
considered to be too important a matter, as regards the comfort and
welfare of parturient women, to be overlooked or lightly regarded.
The Treatment of Placenta Praevia, — Murphy (" Brit. Med. Jour.")
reports fifteen cases of this complication, in all of which the mothers
recovered, recovery being delayed in one case, however, by an attack of
phlegmasia dolens. Five of the children were born alive, but three
only survived, and four of the others were dead when the patient was
first seen. In regard to the causes which produce haemorrhage (ante
partum) in cases of placenta praevia, the author follows Matthews Dun-
can in considering that they may be (1) rupture of a utero-placental
vessel, (2) rupture of a marginal utero-placental sinus, (3) partial sepa-
ration of the placenta from accidental causes, as a jerk or a fall, (4)
uterine pains from attempted miscarriage which is arrested at an early
stage. Miiller is quoted as stating that haemorrhage is most frequent
in cases of complete placental presentation between the twenty-eighth
and thirty-sixth weeks ; in the incomplete forms it usually comes after
the thirty-second week. After such a warning as is given by haemor-
rhage at this period, the sooner labor is induced the better the chances
for both mother and child. The operation which will be required is
the same in principle, whether labor has begun or not, and the author
is very decided in his opinion that the vaginal tampon is not the means
which is required. Immediate dilatation of the os is the end which is
to be attained. Tents or the finger may first be used, and then Barnes's
hydrostatic bags, or Steele's modification of the same. After a moder-
ate degree of dilatation has been effected the finger should be passed
into the uterus, and should separate all the placenta which is contiguous
to the os internum. If uterine pains occur, the haemorrhage will cease,
the theory being that the vessels in the detached portion of placenta
contract with the contractions of the uterus, and do not drag upon the
vessels which are still intact as they did before the placental separation
was effected. If haemorrhage does not cease, ergot should be given.
Dilatation being accomplished, the case may be left to nature. Rapid
delivery may be effected with the forceps, but in the majority of cases
version will be the most appropriate operation.
Defective Lactation. — Dolan {Ibid.) cites the following general
principles upon this subject: 1. All therapeutical, agents intended to
act on the mammary gland must first enter the blood, or be capable of
stimulating the blood supply in the mammary apparatus, the principle
being that nutrition is dependent on blood supply. 2. Drugs from the
families Liliacece, Crucifera:, Solanacece, Umbelliferce, etc., enter the
blood and impregnate the milk, so that poisons in any of these classes
must be administered with caution to the mother or nurse. 3. There is
no true galactagogue, but jaborandi is the nearest approach to one. Its
action is not persistent, however, and it affects the mammary secretion
only temporarily. 4. Belladonna is an autigalactagogue. 5. In inac-
tion of the mammae the milk may be increased and influenced by medi-
cines. 6. The salts of milk may be improved, as to quantity, by the
action of medicines. 7. Various physiological actions, purgative, alter-
ative, diuretic, etc., may be produced in the child by the administration
of drugs to the mother. 8. Diet and hygiene must be regarded in
order to effect improvement in the milk-secreting power. In regard to
the causes of defective lactation: 1. They may be mechanical (a)
through non-development of the lactiferous tubes ; (&) through non-
development of the caecal terminations of the ducts ; (<•) through nou-
perfection of epithelium. These conditions can not be remedied,
Plethora can be remedied by suitable, non-stimulating, nutritious diet.
2. Torpor of the mammae may be overcome by repeated applications of
the electric current, by irritation of the nipple, warm poultices, and the
breast pump. 3. The commonest cause of defective lactation is ana'-
mia, which is associated with constitutional degeneration. This radical
defect is shown to be a very common condition, especially anioiu; the
overworked and underfed laboring population in manufacturing com-
munities. A degeneracy of the race, at least in so far as these classes
192
MISCELLANY.
[N. Y. Mkd. Jodb.,
are concerned, is steadily progressing. One great remedy which is sug-
gested consists in counteracting the vice of intemperance. The num-
ber of places of refreshment and entertainment for the poor should he
greatly increased, and coffee, cocoa, tea, milk, soup, vegetables, etc., be
furnished at low prices, the object being to displace with establish-
ments of this character the present evil system of public-houses and
dram-shops. The best mothers and the least amount of degeneracy
are, says the author, in the middle classes. Woman's mission must
ever be regarded in its association with motherhood, for the accom-
plishment of which important evolutional and nutritive changes must be
undergone. If the forces which are involved in the process of repro-
duction are weakened, the result is necessarily a weakening of the race.
Therefore the necessity of surrounding the function of lactation with
proper safeguards can not be overestimated.
UHstjellattp .
The International Medical Congress. — Dr. D. Bryson Delavan, of
New York, authorizes us to announce that he has declined to take part
in the Congress as at present organized. The " Medical News " an-
nounces the withdrawals of Dr. Hunter McGuire, Dr. S. P. Moore, and
Dr. James B. McCaw, of Richmond ; Dr. Le Grand X. Denslow, of St.
Paul ; Dr. John L. Atlee, of Lancaster ; and Dr. Joseph R. Smith, of
the army.
The situation continues to be made the subject of comment by sev-
eral of our contemporaries. The " Kansas City Medical Record" says:
" In the June number of the ' Record ' we partly gave way to our feel-
ings regarding the outrageous action of a few supercilious nabobs, who
have nothing to lose by any disturbance created in the medical profes-
sion. In our article we suppressed much of our disgust, with the hope
that all dissatisfaction might be peacefully settled, and the profession
appear as a unit in trying to make the international meeting what it
should be — a well-merited credit to the American medical profession.
It now seems that we are to be sadly disappointed in this our wish.
" The new committee appointed at New Orleans met at Chicago
about the end of last month. A few members of the original com-
mittee met with them, but, of course, being in a hopeless minority, were
forced to submit, which they did with apparent grace. Dr. Austin
Flint, Sr., chairman of the original committee, sent in his resignation,
which was quickly accepted. This showed the direction of the wind,
which has nearly destroyed the Congress.
" Dr. Flint did the correct thing in resigning, as he was not the
chairman of the new committee ; but the committee did a very unwise
thing in accepting the resignation. This first act of the committee was
a direct blow at the original committee. The leading physicians of
Philadelphia led off in their unqualified condemnation of the action
taken at the Chicago meeting, and were soon followed by the profession
of Boston, Baltimore, and other places. We are sorry to see this grow-
ing dissatisfaction, which, if it continue, will ruin the Ninth Interna-
tional Medical Congress. It may be noticed that the men whose names
appear among the disaffected in the different organizations are the rec-
ognized leading members of the profession, who have always occupied
a front rank in medical association meetings. Hence, with these men
withdrawing from the committees, it looks very cloudy for the Wash-
ington meeting in 1887."
The " Columbus Medical Journal " says : " The fear that we ex-
pressed a couple of months ago bids fair to be realized ; the Texas kick
has ' overturned the fat into the fire.' In other words, the officers of
the Congress, as selected by the new committee, are very generally re-
fusing to serve ; at least, such is the case with those from Philadelphia,
Boston, Washington, Cincinnati, and Baltimore, while numerous other
resignations have come in from other cities. Many of the most impor-
tant sections have thus been left without officers. Five of the original
committee of eight have resigned, including Dr. Billings, and the secre-
tary general has also declined to serve. Matters have, indeed, assumed
such a shape that no one with any self-respect can afford to take the
places thus left vacant. To be a second choice, even under the most
favorable circumstances, is always sufficiently humiliating ; but to con-
sent to be such in the present crisis would certainly indicate an utter
absence of professional pride. We are told of three London tailors
who once met and ' Resolved, that we, the people of England,' do thus
and so. It now looks as though about the same number of 'kickers'
would gather themselves at Washington, two years hence, and call them-
selves an International Congress."
"The cry against the 'new-code' men was all bosh. It was raised
at New Orleans simply to divert attention from the real purpose of
those who uttered it, on precisely the same principle as the matador
flaunts his red flag in the face of the bull. A few sharp and unscru-
pulous politicians — who had no claim to recognition in the organization
of the Congress, and had hence received none — used that cry as a
means of foisting themselves into prominence. They succeeded in
their ruse, but ' vaulting ambition o'erleaped itself,' and the Congress,
under their management, is hopelessly fated. They have come to a
realizing sense of this fact, and, anxious to stand from under, are now
wildly endeavoring to make themselves, and others, believe that the
blame for the failure must rest on those who have withdrawn ! They
may deceive themselves by such audacious claims, but surely no one
else."
The " Medical Record " publishes an open letter addressed to Dr-
John V. Shoemaker by Dr. Henry D. Noyes, of New York, from which
we extract the following : " With the excisions and withdrawals of our
ophthalmologists and of other medical men can we still offer induce-
ments powerful enough to bring to us the men we want from Europe V
Can I explain to my confreres in Germany, Switzerland, Paris, and Lon-
don, who expressed their intention of coming and who loaded me with
hospitalities — can I account for these withdrawals and exclusions in
any way which will not bring disgrace upon our medical profession ?
" The situation is profoundly critical, and failure is certain unless an
absolute reversal of the present policy is quickly effected. The delegate
idea must be abolished. The pledges given at Copenhagen must be car-
ried out in good faith to the letter. This means that men who have
been treated with indignity must be invited back. To do this is not
pleasant to human nature, but it is manly, and it is imperative. The
Congress must be free to all physicians of honorable standing. Better
to have a sprinkling of unworthy men, or of irregulars, than to persist
in the mischievous and suicidal course now causing disintegration. Nor
can we long delay. To wait until next May is to multiply difficulties
and aggravate evils. The officers of the American Medical Association
and the new committee should take the responsibility of such measures
as will be radical enough to restore confidence, to bring back harmony,
and to counteract the distrust which will spread through Europe most
rapidly and be counteracted very slowly."
The " Virginia Medical Monthly " says :
" We are not surprised, and must confess being glad, at seeing with
what almost unanimous action on the part of the leading members of
the profession the result of the Chicago session of the newly appointed
committee has been met. The resignation of nearly every prominent
appointee on the full committees and sections made at that session
shows a feeling of dignity and self-respect ; and the fact that so many
physicians in different parts of the country have expressed their sym-
pathy with that action is plainly indicative of a feeling that something
is more than wrong in the position taken by the American Medical As-
sociation at its late meeting in New Orleans. The thing to be sorry
for is not the fact of these meetings in different citie< and the action
there taken by the doctors present, but the fact that all this was made
a necessity by the personal ambition of some men who felt that they
had been slighted.
" The medical press of England has already referred in no compli-
mentary terms to this last-mentioned subject, and the action of the as-
sociation has not tended to increase the respect of our professional
brethren across the water.
" It is most certain that, unless some new action is taken in refer-
ence to the committee formation, the Congress will be a failure — a thing
which must not be allowed to occur, and, although we acknowledge the
shortness of the time which will elapse between the 1886 meeting of
August J 5, 1885.]
MISCELLANY.
193
the American Medical Association and the 1887 meeting of the Inter-
national Medical Congress, it seems to us the only thing now to do is at
the next association meeting to wipe out by careful legislation all exist-
ing committees, and appoint an entirely new one — not on the narrow
basis of a printed set of rules rapidly becoming obsolete by the advance
of thought and charity — but on the broad platform of fraternity, hon-
esty of purpose, and dignity."
The " Medical News " publishes the following preambles and reso-
lution, adopted by the Dallas County (Texas) Medical Society, at a spe-
cial meeting held July 25th :
"Whereas, The American Medical Association, at its meeting in
Washington city, in May, 1884, recognized a general desire of the medi-
cal profession of the United States by adopting a resolution under
which a committee was appointed whose duty it should be to extend an
invitation to the International Medical Congress, shortly to assemble at
Copenhagen, to hold its next meeting in 1887 at Washington city, D. C,
and
" Whereas, The said committee, by the letter and spirit of this reso-
lution, was fully empowered to act, not only as a committee of invita-
tion, but as an executive committee as well, and
" Whereas, The said committee, in pursuance of the objects of the
above-mentioned resolution, and duly exercising the unlimited authority
delegated to it, enlarged its membership and otherwise provided for the
successful holding of an International Medical Congress at Washington
city, in 1887, all of which arrangements were considered by us as ju-
dicious, and, contrary to what has been charged by some, wholly disin-
terested as to personal or local aggrandizement, and
" Whereas, The American Medical Association, at its last meeting at
New Orleans, did, in our judgment, unwisely and untimely, virtually
rescind its former action, which reactionary movement has deranged,
if not indefinitely suspended, the work of the original committee which
was satisfactorily progressing, and created an indifference to the Con-
gress among recognized leaders of medical thought and interest through-
out the country, and
" Whereas, There are those who persist in urging the so-called jus-
tice of their claims for the organization of the International Medical
Congress on a territorial basis, which unfortunate idea has been un-
wisely further extended by some members of the profession in Texas
in a manner calculated to arouse a sectional prejudice, which has little
if any existence in our State ; therefore be it
"Resolved, That the Dallas County Medical Society deplores what
must be considered the present interregnum in the affairs of the con-
templated International Medical Congress, brought about, as we believe,
by an ill-considered and hasty action at the New Orleans meeting be-
fore mentioned ; that this society was fully satisfied with the work of
the original committee, which was composed of able, eminent, and con-
scientious members of the profession ; that this society repudiates anv
attempt to inject a sectional feeling into a purely professional matter
which has reference to scientific investigations only, and that said at-
tempt, if offered in behalf of the medical profession of Texas, is in
the opinion of this society, both unauthorized and gratuitous ; and
that, looking beyond a narrow-minded policy of personal aggrandize-
ment and sectional interest, we heartily commend the recent action of
Philadelphia and New York brethren, as well as those elsewhere, who
have retired from the Congress until a more dignified and unselfish
view of the arrangements can be had ; and we pledge them our heartv
support and good-will in their efforts to advance the interest of the
American medical profession in future meetings of International Medi-
cal Congresses, where the truly representative medical abilities of our
country shall be enlisted uncontrolled by geographical lines or personal
preferences."
In its editorial columns, the same journal says :
" Rapid disintegration still characterizes the new organization of the
Congress. This week we are called upon to chronicle more resigna-
tions, and the list includes one vice-president of the Congress, three
vice-presidents of sections, and several members of councils. The very
large number of appointees who have declined to accept office under
the New Orleans committee are all old-code men, both in principle and
practice, and for the most part they are members of the American
Medical Association. They recognize the falsity of the issues which
were raised at New Orleans, and they have promptly placed their em-
phatic seal of condemnation upon the most disgraceful piece of intrigue
which has yet marred the history of that body, and which is in immi-
nent danger of placing an ineffaceable stigma upon the good name of
the whole American medical profession.
" Although the hollowness of the code cry has been fully exposed,
we still find it being freely used by the new committee, and we learn
that a circular, to which signatures are invited, has been extensively
circulated through this State, expressing approval of the exclusion of
the new-code men from membership in the Congress and applauding
the work of the committee at Chicago, and it is headed ' The Action of
the American Medical Association indorsed.' The first response it
appears to have elicited was the resolutions condemnatory of the action
at New Orleans, which were passed by .the Alleghany County Medical
Society and published last week, and this week we hear the echo from
Texas.
" The profession recognizes that on account of recent events there
is imminent danger of its not being able to meet the obligations which
it incurred by the invitation extended in its name at Copenhagen, and
its members naturally look around to see what means can be found to
avert the impending disaster which threatens to defile its good name.
" The clearest and cleanest way out of the false position into which
the profession has been entrapped by the plotters at New Orleans is for
all appointees to discredit them completely by declining to accept office
at their hands, and thus their organization must, of necessity, collapse.
Already this has been largely done, and upward of one hundred and
twenty of the most eminent of their appointees have declined to be
tools in their hands, and the sooner the remainder follow suit the sooner
will the way be opened to the profession to redeem its plighted honor."
The " American Practitioner," of Louisville, says :
" At its meeting in 1884, the American Medical Association selected
eight of its members to visit Copenhagen and invite the International
Medical Congress, then in session in that city, to hold its next meeting,
in 1887, in the United States. The invitation was given by the associ-
ation in the name of the profession of America. It was accepted, and
the committee which conveyed it was at once adopted by the Congress
as its own, and invested with the necessary powers of organization and
all its et ceteras. The committee, while away, acquainted itself with the
accustomed mode of organizing and the methods of work of the Con-
gress. It was informed by the founders and chief promoters of the
Congress that the work of this body was confined to science, pure and
simple ; that every other business was vigorously excluded ; that its
membership was catholic in the broadest sense of that term ; that it
knew neither geographical lines nor sectional lines, but embraced the
workers of every clime and nationality ; and, finally, that the only ethi-
cal test required of applicants seeking admission was that they should
belong to the universal brotherhood of legitimate science. The com-
mittee returned home and entered without delay upon the discharge of
the duties with which it had been intrusted. These duties involved
much labor and great responsibilities. They were completed in season
to present the result in detail at the meeting of the association in New
Orleans in May. The plan of organization advised by the committee
was that under which all previous sessions of the Congress had been
held. In a word, the committee simply acted upon information derived
while abroad. This information it embodied in its report. The report
itself was modeled on that of every preceding Congress.
" When the secretary of the committee read this report at New Or-
leans, it met with the most extraordinary reception. It was not even
accorded the common courtesy of being received. Instead, it was as-
sailed on the floor of the association in language too coarse to be re-
peated, and the committee itself was openly charged with narrow-mind-
edness, partiality, selfishness, bargain, intrigue, and corruption.
" The committee, as originally composed, consisted of Austin Flint,
John Billings, Minis Hays, H. F. Campbell, L. A. Sayre, George J.
Engelmann, Christopher Johnston, and John M. Browne, of the navy.
" Acting under the resolutions which called it into existence, it had
added thirty-four other members, representing names in every respect
worthy of being associated with the foregoing. Of this committee,
consisting now of forty-three members, but five were present when the
handful of agitators bent on revolution rose iu the association. The
194
MISCELLANY.
[N. Y. Med. Jour.,
names of none of these men had appeared in the organization of the
Congress, as reported by the committee.
" Many persons profess to have seen in this omission the mainspring
of their action. They spoke much and often and well. They ap-
pealed to sectional prejudice and were applauded. They indulged in
endless personal animadversion. The air was made thick with charges
against the committee which their authors could not have believed to
be true, but which, serving their purpose for the hour, they used with
no little effect. The most offensive of these was reiterated with great
vehemence by one of the speakers. Not many days after it was proved
to be groundless, and its author branded in the public prints as a de-
liberate falsifier.
" During the time just described the wildest confusion prevailed on
the floor of the association. Cries of ' Order' went up from all parts
of the house. Scores of men rose simultaneously to their feet in at-
tempts to catch the eye of the speaker, or to clamor for the preserva-
tion of order. The gavel of the presiding officer fairly rattled, but in
vain. There was no order. An eye-witness likened the hall of the
association at this moment to pandemonium.
" It is reported that one of the more violent of the revolutionists
expressed a desire to see certain officers of the Congress strung up by
the neck, and declared himself willing to adjust the fatal noose.
" The secretary-general of the Congress finally succeeded in getting
the floor. He made a plain and manly statement of the work of the
committee, counseled conciliation, and gave a flat denial to every charge
reflecting upon the honor, fair-mindedness, and integrity of the com-
mittee. But his effort to stem the current was quite unavailing. The
sober-minded members present sat bewildered, and the association was
hurried into the deplorable blunder of repudiating the report of the
committee and practically impugning the motives of the committee-
men.
" In the face of its own resolution passed the year before, and un-
der the sanction of which the work of organization had been carried
on, the association declared void every addition to its members made
by the committee, and took the business into its own hands. ■ It at
once appointed a member fiorn each State and Territory, and a repre-
sentative each from the army and navy — in all, thirty-eight. It then
clothed this new committee with the power to undo, if it thought fit,
the entire work of the committee of 1884. It gave it no instruc-
tions.
" The committee organized at once by electing a temporary chair-
man and secretary. It held its first meeting for business at Chicago in
June. There were present twenty-five of its own members and three
members of the original committee. After electing the temporary offi-
cers to the same positions in permanency, they proceeded to eject the
new-coders from office and fill their places with men loyal to the old
code.
" They then lessened the number of sections, as created by the
original committee, by merging here and there two sections into one.
They subsequently cut out many names from the North and East which
they replaced by names from the West and South. They added largely
to the list from the latter portions of the country, and procured a repre-
sentation from a much more extensive territory than had been embraced
by their predecessors in the work.
" They withdrew the right of presidents of sections to have a voice
in the selection of their co-workers and associates, whereby these offi-
cers were dwarfed into mere creatures of the committee. They finally
denied representation in the Congress to such physicians as were not
members of the National Association, or of societies in affiliation with
it. The committee then adjourned. So much by way of history. The
committee made no report of its work ; but its operations soon came to
be known.
" The behavior of the association but sixty days before was yet
fresh in the public mind. There was a widespread feeling of misgiving
and regret, coupled with the hope that the Chicago committee would in
some way atone for the wrong and injustice done the profession at large
and the original committee at New Orleans. But its action instantly
destroyed such hope and confirmed the gloomiest forebodings. The
committee chose as its officers men who, whatever may be their talents,
had led the movement at New Orleans, and secured themselves in office.
Many physicians who had accepted position in the Congress from the
original committee, despairing of the success of the undertaking in its
new hands, determined to withdraw from the organization. Others,
saying openly they would not serve under such officers, also withdrew.
" The meetings of the profession in Philadelphia, Boston, Baltimore,
Washington, and Cincinnati, not to mention individual instances in other
places, bear witness to the extent and earnestness of this feeling. Every
day has brought fresh accessions to the list of those who decline to fol-
low such leaders. And, as the facts of this unfortunate business be-
come more generally known, it is safe to say that the list of those who
distrust the leaders of the revolution inaugurated at New Orleans will
grow apace.
" Much was said at New Orleans and elsewhere about the code ques-
tion in connection with the Congress. Such gentlemen as have seen
fit, for reasons, to withdraw from the Congress as at present organized,
have been accused of being unfriendly to the code and supporters of the
new code. Philadelphia was the birthplace of the code. There it was
ingrafted on the constitution of the American Medical Association, and
first offered as the creed of the profession in the United States ; and
there, if anywhere, is its spirit a living spirit, and does its letter carry
the force of law. And yet Philadelphia physicians were the first to
take up arms against the New Orleans movement ; but the question of
code was not in their minds. They well knew how adroitly and with
what effect it had been used at the National Association, but, when they
met to record their objections to the Congress passing into the hands of
its present leaders, the code was never once mentioned. It was not
thought of. The motives which influenced them and the causes which
led them to decline to accept office in the Congress under its new or-
ganization were of another and very different kind. They raised no
objection to the action of the committee on the code, though some of
the more conservative of them may have doubted the wisdom of a step
which turned upon a point that the Congress had never considered^
and, from the very nature of its organization and the spirit by which it
was guided, could but believe was beneath its dignity to consider.
"The Philadelphians were fully alive to the fact that, notwithstand-
ing the war of the factions in New York, the code men continued to
associate with the new coders in school, hospital, and society, and even
meet them in consultation.
" When Dr. Leidy and Dr. Agnew, Dr. Da Costa and Dr. Stille, Dr.
Horatio Wood and Dr. Gross and Dr. Parvin and their coadjutors met)
their purpose was to withdraw from the Congress for the simple reason
of distrust in its new management. They felt aggrieved at the be-
havior of the association at New Orleans. They were dissatisfied with
the action of the committee at Chicago, and they went to record to this
effect.
" Whether the gentlemen who in other cities have come to book in
similar resolutions were influenced by similar reasons is not germane
here. Philadelphia led off in the movement. That this same feeling
of distrust — not to use a stronger word — reaches to very many other
places, no observant man will deny. That it exists to such degree,
that it exists at all, affords cause for the liveliest apprehension. That
it will acquire such proportions as may lead the National Association to
call a halt and undo some of the work it did in such unseemly haste at
New Orleans, remains to be seen.
" The conjecture is certainly grave enough to make such action
reasonable. And. if wisdom united to courage and the charities direct
and control the association, it may still recover from the stab inflicted
with its own hand at New Orleans, and bring the sessions of the Inter-
national Congress in 1887 to a successful close. Otherwise the fate of
the association, no less than that of the Congress when it meets on
American soil, is easily read. The end of one will be disintegration
and decay. That of the other will be mortifying failure. These are
strong words, but sober withal.
"A medical man of Philadelphia, of enviable name, was asked a
short time since by the secretary of the new committee if he could sug-
gest a way by which the differences between the profession and the
association could be adjusted. He answered, ' By your resigning.'
This may, or may not, afford a key to the situation. But it clearly sig-
nifies that certain things done both at New Orleans by the association
and at Chicago by the new committee must needs be undone before
August 15, 1895.]
MISCELLANY.
195
surcease can be had of the present discord. If this be not effected,
those who have thrown up commissions derived from the new leaders
will take neither part nor lot in the matter. And while it goes without
the saving that this action will in no wise affect the coming of the Con-
gress at its appointed time, it will surely rob the meeting of all interna-
tional character, which, in the opinion of its founders and its friends,
has been the chief and most valuable feature of the organization.
" One or two thoughts, growing out of events which have occurred
since the association meeting in New Orleans, here suggest themselves.
When it is considered that almost every man who has declined to serve
under the present regime of the Congress is a member of the American
Medical Association, does it not mean that there is a strong feeling of
dissatisfaction with the action of the association ? When this feeling
is made manifest from Massachusetts to Maryland, from the District of
Columbia to Missouri, from New York to Ohio, and from Pennsylvania
to Kentucky, does it not mean that the feeling is a somewhat general
one ? Nor should it be lost sight of that there are many sections of
country which have not yet expressed themselves on the subject.
" The question has been under discussion for now a full month.
Both sides have had a hearing. How stands the medical press on the
subject ? Let the reader turn to his journals and see. Can any of
these things be denied ? Is the man not purblind who fails to see that
the National Association has, by its conduct, imperiled its influence and
usefulness, if not its very existence ? There is a profession outside the
association whose voice it would be well for the present managers of
that body to give ear to. The invitation to the Congress was given in
the name of the profession of the United States. Perhaps the associa-
tion had no authority to do this, but it was done nevertheless. The
membership of the association represents but three thousand of the
forty thousand men who win their bread by the practice of medicine in
America. The Congress, in whatever kingdom it has hitherto held its
sessions, has thrown wide its doors to all respectable members of the
profession throughout the world. Neither ethics nor the matter of
membership in this or that society ever came before the Congress. Its
plane of work was broader and better than that. It has hitherto rep-
resented the beneficent spirit of science and that only. It has remained
to the National Association of the United States to set up a new stand-
dard for admission. Fortunately, it is not too late to remedy that
blunder, and such part of it at least as affects the profession at large
will be changed when the new committee meets in New York in Sep-
tember. This will add both to the membership and dignity of the
Congress.
" What will be the outcome of this deplorable muddle it is alto-
gether impossible now to say. The committee, aided by older and wiser
heads than those who have hitherto directed its movements, may hark
back and find a path which will lead the association out of its present
dilemma, and up to the point of organizing a truly International Con-
gress worthy alike of its noble aims and of the great guild which bids
it come to our land. If the committee fails, especially if it fails through
unworthy ambition, love of patronage, or, worse than all, through greed
of office, it will realize before this business is finished that wreckers are
sometimes wrecked, and revolutions are often fatal to their leaders."
The "Kansas City Medical Index" says:
"It seems too bad that sectional jealousies in the United States are
so great that they may be the means of wrecking the next International
Medical Congress appointed to meet at Washington in 1887.
" We are exceedingly sorry the affair has assumed this shape. It
appears to be the opinion of many that the American Medical Associa-
tion at New Orleans acted rashly and hastily in interfering in the mat-
ter, and whether they had the authority to act at all is questioned.
" There will be two more meetings of the association before the
International Congress meets, hence we hope there will be time to heal
old sores, and eveiything be made harmonious."
In a pamphlet entitled "Shadows in the Ethics of the International
Medical Congress," Dr. Levi C. Lane, of San Francisco, Professor of
Surgery in the Cooper Medical College, says ;
"For the information of readers who have not followed the Inter-
national Medical Congress through its phases of change .since it was
decided to hold the next meeting in this country, it may be stated that
the original committee of seven men, to whom the American Medical
Association in 1884 gave the matter in charge, being invested, in ac*
cordance with the act creating the committee, with full powers to per-
fect such arrangements as would secure a successful meeting, proceeded
to outline the work that was to be done, by the creation of nineteen
sections, representing in detail every department in the science of
medicine.
" This division of the work, copied mainly from the method pursued
at the preceding sessions of the International Medical Congress, was
assigned to a like number of committees, composed of medical men
selected from different sections of the United States.
" The American Medical Association, at its recent session in New
Orleans, declined to accept the work done by the committee appointed
the previous year, and created a new one, with instructions to revise and
change the work of the former committee in whatever way it might see
fit. No impartial mind will admit that there was need of revision and
change of the work done by the first committee ; and it is greatly to
the credit of nearly one third of the delegates at New Orleans that they
strenuously opposed it. What a chaplet is this discord to place on the
grave of Dr. Thomas, who, in the discharge of his duties as a co-laborer
with the old committee, lost his life ! What a recompense to Drs. Flint
and Billings, through whose personal efforts at the last meeting the
Congress was induced to hold its first session in the New World ! Their
scourging finds an analogue in the fate of Columbus, who was borne in
chains over the ocean across which he was the first to lead the Old
World. How edifying this spectacle to the eyes of the Pasteurs, Char-
cots, Virchows, Volkmanns, Esmarchs, Listers, and Pagets, who are
expected to honor w ith their presence the coming Congress !
" I am not now, nor have I ever been, connected with the new-code
movement, either here or elsewhere ; in fact, the subject has never been
a matter of division on this coast. I am a member of the American
Medical Association, and, as a duly accredited delegate, I represented
that body not long since in the British Medical Association, and my
mission was not dishonored by ostentatious show there or elsewhere,
during a sojourn of over two years, during which I met the leading men
connected with the medical institutions of Great Britain, Sweden, Rus-
sia, France, and Germany. I am a member of, and very recently presi-
dent of, the State Medical Society of California, from which Dr. Cole
was sent as delegate to New Orleans.
" The honors conferred on me by the original Committee of Arrange-
ments were given unasked for. I had already sketched out some work
as a contribution on a topic of surgery, in which I have had much ex-
perience ; besides, I was in negotiation with a man of wealth for the
establishment of an international medical prize for researches upon
typhoid fever. These facts are here mentioned to show that I had not
entered on this labor with an idle hand."
The " Lancet " for August 1st says :
" We regret to have to inform our readers that the ill feeling which
has been excited in the United States by the action of the committees
appointed to carry out the preliminary arrangements are such as to im-
peril not only the success of the Congress in 1887, but the very exist-
ence of the Congress itself. We have already mentioned the main
facts in the dispute. At the meeting of the American Medical Asso-
ciation held in Washington in 1884 a committee of seven was appointed
to act as a deputation to the Congress in Copenhagen to invite the Con-
gress to the United States for its meeting in 1887. The invitation was
accepted, and the committee forthwith proceeded to carry out various
preliminary arrangements, and, among other matters, to make nomina-
tions for the officers of the different sections in the Congress. At the
meeting of the American Medical Association in New Orleans in May
of this year, a resolution was passed repudiating this latter action of
the committee as being ultra vires, and another and larger committee
was appointed to make all the preliminary arrangements for the Con-
gress. This committee was nominated largely ou a geographical basis,
each State sending a representative. Very naturally this action of the
association gave great annoyance to the members of the earlier com-
mittee and to their associates in the earlier steps of the proceedings.
The larger committee recently met at Chicago, and is«ued a loug list
196
MISCELLANY.
[N. Y. Med. Jock.
of officers of the various sections in the Congress and of the members
pf committee. Many of the names on the earlier list are not to be
found on the latter, and it is stated that the new list contains the
names of some men introduced for geographical reasons rather than
on account of their high scientific attainments — that an attempt
has been made to have the officers representing as much as pos-
sible all parts of the Union. Into the merits of this question we can
not enter. And now we learn that many of the leading practitioners in
New York, Washington, Boston, Philadelphia, and Baltimore are so
offended at the action of the American Medical Association and its new
committee that they have publicly severed themselves from the Con-
gress, and allege that they will have nothing to do with the meeting in
1887 if the arrangements for it are to remain in the hands of the pres-
ent committee. We can not discuss the merits of this far from edify-
ing quarrel, but we are too greatly interested in the International Medi-
cal Congress not to raise our voice in protest against a state of matters
which is both a professional scandal and a serious peril to the continued
existence of the Congress. Hitherto it has been considered binding
upon all participating in the Congress that medical politics shall be
entirely excluded from all its proceedings. But, apart from that, we
must impress upon our American friends the simple consideration that,
unless the whole profession in the United States combine cordially in
the work of the Congress, the meeting in Washington is foredoomed to
failure. Party spirit is so alien to the whole spirit of the International
Congress that a large proportion of those who have previously joined
in the meetings would certainly, and with justice, refuse to visit the
United States to be the guests of a faction. But we have too high an
opinion of our Transatlantic friends to believe that this unseemly
quarrel, which is disgracing them throughout Europe, will be allowed
to continue. We trust that moderating influences will be brought to
bear upon both parties, and that, forgetting the past and their own per-
sonal predilections, they will cordially unite to promote the success of
the meeting in 1887. If, however, the breach now formed is allowed
to widen and deepen, it will be the duty of the officers of the Congress
in Copenhagen to seek at once an invitation from some country in which
the medical profession will not find it impossible to combine for inter-
national purposes."
The Health of Michigan. — We are indebted to the secretary of the
State Board of Health, Dr. Henry B. Baker, for a summary of returns
for the month of July. It appears that diphtheria was reported from
sixty places, scarlet fever from thirty-four, and measles from fifteen.
Errata. — In Dr. Craig's article, published in our last issue, the fol"
lowing errors should be corrected : Page 155, in the formula, for " § iv "
read page 156, first column, twenty-third line, for " September
30th " read September 3d.
Phrenology and Traumatism. — " You have large imagination ; you
ought to write poetry," said a phrenologist to a man whose head he
was examining. "I do write poetry," replied the individual, "and the
bump of which you are now feeling was caused by a blow from an
editor to whom I offered a poem. Please don't bear on so hard."
THERAPEUTICAL NOTES.
Odorless Iodoform. — Oppler (" Ctrlbl. f. Chir.") states that he has
accidentally found that coffee completely masks the odor of iodoform.
Roasted coffee should be very finely powdered, and mixed with the
iodoform in the proportion of thirty, forty, or fifty per cent. The fol-
lowing formula? are given :
Iodoform 2 parts ;
Coffee 1 part.
Mix, with the aid of a few drops of Hoffmann's anodyne. [It is
stated that the addition of the latter is not essential. ]
Iodoform 3 parts ;
Paraffin ointment 30 "
Coffee . . .• 1 part.
Mix ; make an ointment.
The antiseptic power of coffee is mentioned as in itself an advan-
tage.
Quillaia as a Substitute for Senega. — Robert ("Ctrlbl. f. klin.
Med.") has found senega open to certain objections as an expectorant,
although its efficiency is undeniable. Its taste is disagreeable and it is
apt to provoke either vomiting or diarrhea. Its action, he states,
depends on two glucosides, both of which are found in various propor-
tions in different commercial specimens of the drug. Moreover, it i6
dear. The author has found that quillaia, which is much cheaper, con-
tains about five times as much of the same glucosides, and in more
constant proportion, while it is much more agreeable to the taste, and
does not disturb the digestion. Clinical experience has shown him that
its expectorant powers are unquestionable. He uses a decoction of 5
parts of quillaia to 200 parts of water, of which the dose is a teaspoon-
ful for children and a tablespoonful for adults. Intestinal and gastric
ulceration is a contra-indication to its use, as undue absorption by the
ulcerated surfaces may lead to poisoning.
The Use of Cocaine during Labor. — Dok'ris (" Compt. rend, heb-
dom. des seances de la soc. de biol." ; " Ctrlbl. f. klin. Med.") has used
cocaine in six cases of labor, either in solution or in the form of a four-
per-cent. ointment, with the view of mitigating the pain of the dilata-
tion period or that of the expulsive period. In two cases the measure
failed, probably because the cocaine was decomposed by the remnants
of a corrosive-sublimate injection that had previously been thrown into
the vagina.
The Use of Iodine in Diphtheria. — Adamson (" Practitioner ") adds
his testimony to the efficiency of the iodine treatment. He lost only
two patients out of fifty-five treated with the tincture alone, although
some of the cases were very grave. For adults he gives from five to
seven minims every hour, and for children between six and twelve
years of age from two to three minims every two hours. Special
mention is made of syrup of quince for disguising the taste of the
drug.
Hopeine. — This alkaloid, which appears to be different from the
lupuline of Griessmayer, is described by W. T. Smith, of London
(" Dtsch. Med.-Ztg."), who refers to previous investigations by William-
son and Springmiihl, who gave it the name of hopeine. It is said to be
most abundant in the American wild hop. It occurs as a white crystalline
powder, or in the form of needles a third of an inch long. It is very
sparingly soluble in water, but dissolves freely in alcohol, the solution
having the most intense bitter taste and a pronounced smell of hops.
Chemically, it bears a close resemblance to morphine. In its physio-
logical action it is a pure narcotic, even fatal doses producing no irri-
tant effect ; but it contracts the pupil, raises the temperature, and in-
creases the frequency of the pulse at first, but afterward diminishes it.
The deep sleep which it induces is apt to be preceded and followed by
peculiar hazy hallucinations. The author has used it as a hypnotic, in
doses ranging from one third to six tenths of a grain for adults, and
in his own person he found that three quarters of a grain produced
symptoms of poisoning. He finds that the dose does not have to be
increased on account of the system becoming habituated to the drug.
He thinks that the " toxic dose " is not much above a grain and a half
for adults, and not over nine tenths of a grain for children.
The Treatment of Puerperal Eclampsia with Hot Baths. — Breus
(" Arch. f. Gynak." ; " Rev. med. franc, et etrang.") reports that he
has continued his experiments in the use of hot baths as a remedy
for puerperal convulsions, and has now treated seventeen patients by
that method, with only one death. If there is albuminuria, that, too,
is favorably affected by the baths. He first puts the patient into a
bath of about 100° F., and gradually carries the temperature up to 104°
or 106°. He has not found that either abortion or hemorrhage is
favored by the treatment.
The Treatment of Acute Nephritis. — Aufrecht (" Berl. klin. Woch." ;
" Lyon med.") advises the greatest caution in medication, and particu-
larly the avoidance of diuretics and diaphoretics ; at the most, he uses
iron to combat the anaemia only after the lapse of several weeks. At
the outset the patient must keep his bed, and be allowed only a mini-
mum of nitrogenous food. Light vegetables are to be preferred, and
it is only at the end of a fortnight that milk and broth are allowed.
He cites the case of a child with scarlatinal nephritis who recovered
under this treatment, although there had been suppression of urine for
eighty hours.
THE NEW YORK MEDICAL JOURNAL, August 22, 1885.
(Original Communications.
THE EARLY STAGES OF HUMAN
DEVELOPMENT.
Bt CHARLES SEDGWICK MINOT, M. D.,
BOSTON.
Part I. — Ova of the Second Week of Pregnancy.
There is no comprehensive account of what is at pres-
ent known of the history of the human ovum during the
first month of gestation. It is the object of the present
series of articles to meet this want.
The only tolerable account of what is known of the very
early stages of man's ontogeny is the very admirable review
indeed given by His in the first part (pp. 147-166) of his
great work on the " Anatomy of Human Embryos," a work
which is a veritable masterpiece of accurate and thorough
research. I take the more pleasure in speaking thus as
Prof. His has recently been bitterly attacked by Haeckel in
a manner equally unwarrantable and ungentlemanly. It is
much to be regretted that the critic should have forgotten
his own repeated falsifications, instead of recollecting that
Prof. His was a model whose truthfulness his critic would
do well to imitate. It will be found that, although Prof.
Haeckel has written a large book upon anthropogeny, yet
he has contributed very little of the slightest value to the
science of human embryology, while Prof. His is one of
those who have done most. It is therefore most unbecoming
for the former to denounce the latter with such virulence as
he has displayed. Haeckel's personal dislike is not likely
to affect the recognition of the sound worth of Prof.
His's researches. As I shall have occasion to frequently
cite the latter, it seemed desirable, in view of the criticism
alluded to, to express my estimation of His's work.
The two next best general accounts are : one given by
Kolliker, in his smaller Embryology ("Grundriss der Ent-
wickelungsgeschichte," 1884); the other by Allen Thom-
son, in the ninth edition of Quain's " Anatomy." These au-
thors give, I think, only inadequate summaries of our present
knowledge, which is much more extensive than appears in
their writings. As regards Kolliker, it should be remem-
bered that his book is chiefly occupied with a presentation
of his own observations and bears largely the character of
a series of original investigations, and gives, therefore, less
attention to summarizing the writings of others than might
be considered desirable in an avowed text-book. The em-
bryology in Quain, on the other hand, is professedly a sum-
mary, so that it is specially to be regretted that the distin-
guished author did not prepare an exhaustive revision of
the literature of the embryology of the first month. The
other " embryologies " appended to various "anatomies"
and " physiologies " are, for the most part, second- or third-
hand compilations, none of which, so far as I know, call for
further notice.
Having myself undertaken to prepare a " Treatise on
Human Embryology," to be published, before very long, by
Messrs. Appleton & Co., it became necessary to go over the
literature of the subject afresh. This study leads to results
in many respects widely different from the statements which
have found general currency, so that, pending the appear-
ance of the treatise above mentioned, it has been thought
desirable to publish a review of all that is at present known
as to the course of development of man during the first
month, adding at the same time a sufficient number of illus-
trations to fully elucidate the meaning of the text. This
review will form a short series of articles in the pages of
this Journal.
We may begin by stating that the known human ova
may be divided into two categories — (1) those before, and
(2) those after the appearance of the embryo. The number
pf the former is very small, only seven observations of any
value being known to me. No ova are known which show
the manner in which the embryo arises from the blasto-
derm, and no satisfactory description exists of any embryo
younger than His's embryo Ll, in which the neural tube
was already formed and the brain marked out, the auditory
vesicle present, etc. In fact, we possess an extremely insuf-
ficient knowledge of ova under three weeks, and it is a
matter of rare interest and importance to secure and prop-
erly investigate more specimens of this period. A certain
number of these come into the hands of practicing physi-
cians ; I therefore earnestly exhort the members of the pro-
fession to bear the needs of science in mind and to pre-
serve material which none but them can secure. It may
assist those who are willing to thus aid science to have
some guide for finding and keeping the desired specimens ;
therefore a few brief directions are given below. I need
hardly add that I am very desirous of obtaining young ova
and embryos for purposes of research, and shall feel under
deep obligation to every one who contributes material for my
studies in this field. Of course I shall be happy to meet
any expenses which may be incurred in sending specimens.*
1. HOW TO OBTAIN AND PRESERVE YOUNG HUMAN OVA AND
EMBRYOS.
It is probable that pregnancy usually begins with the
first menstruation omitted. If a woman, in whom preg-
nancy may be expected, and who, being otherwise in good
health, has been menstruating regularly, skips a period, it is
an indication that she has become pregnant. It is by no
means rare that at some time after the omitted period a dis-
charge of blood occurs, and such discharges are frequently
accompanied by abortions. If, therefore, a patient, sus-
pected of pregnancy and having uterine haemorrhage within
two months of an omitted period, be carefully watched,
there is a probability of finding an ovum or an embryo
among the discharges from the uterus, and all such dis-
charges of blood or decidual tissue should be carefully ex-
amined.
If the disturbance occurs within fourteen days of the
omitted period, search should be made for a small, flesh-
colored vesicle, either with short villi or with a partly or
wholly smooth surface. The vesicle will be from one ninth
* Dr. Minot's address is : Harvard Medical School, Boston, Mass. —
Editor.
198
MI NOT: THE EARLY STAGES OF HUMAN DEVELOPMENT. [N. Y. Med. Jock.,
to one fourth of an inch in diameter (3 to 6 mm.). It
should be treated with the greatest care, and on no account
be placed in water or opened. If the disturbance occurs
after a longer interval, a larger vesicle must be looked for,
with the villi much longer and more ramified. As long as
the vesicle measures less than three fifths of an inch (15
mm.), it should be preserved unopened. If the ovum is
larger than this, it should be carefully examined to ascer-
tain where the embryo is attached to the walls (chorion) of
the vesicle, and then the opposite side of the vesicle slit open
with fine scissors, to allow the preserving fluids to pene-
trate.
To Preserve Ova and Embryos. — Above all, never place
them in water or in strong alcohol ; when possible, put a
little cotton-wool in the preserving fluid for the specimen to
lie upon. If it is necessary to carry it a short time before
the preserving agents can be obtained, wrap up the speci-
men in a damp, soft cloth, taking care to avoid all pressure
upon it.
The best method of preservation is, on the whole, by
Kleinenberg's picro-sulphuric acid, which is made by dis-
solving 0*1 gramme of picric acid in 100 c.c. of water, and
adding 0-6 cubic centimetre of concentrated sulphuric acid.
Leave the specimen in this solution for one or two hours,
according to its size, wash it for a few minutes in alcohol of
30 per cent., place it for an hour in an alcohol of 50 per
cent., and then transfer it to alcohol of 70 per cent., in
which it may be kept permanently ; but the alcohol must
be renewed until it is no longer discolored by the picric
acid.
A good method, and much simpler, is to put the embryo
or ovum for five minutes (but on no account longer) in a
mixture of one part of concentrated nitric acid with ten
parts of water. Then transfer to 70-per-cent. alcohol.
The third and simplest method is to place the embryo
directly in 60-per-cent. alcohol, in which it may be kept, or,
better, placed after two days in alcohol of 70 per cent.
Apothecaries can furnish alcohols of the desired
strengths. All these methods require care ; but the value
of the specimens fully repays the trouble.
In sending or transporting the specimens, the jar or
bottle should be very lightly stuffed with fine cotton-wool,
and it must be remembered that a very slight pressure
of the wool will distort the specimen. All that is needed
is to prevent the specimen from shaking about.
2. KNOWN OVA OF THE SECOND WEEK.
Reichert's ovum (1) is to be considered the youngest
normal human ovum hitherto described. It was thought
by Reichert to be twelve to thirteen days old, and' probably
correctly so, as it was obtained at a post-mortem examina-
tion of a young German girl under circumstances which
render the estimate of the age quite trustworthy. The
ovum itself was very imperfectly examined by Reichert,
whose very lengthy memoir deals largely with cognate sub-
jects and contains much speculative matter. The actual
description of the ovum is brief (pp. 25-28) ; but, as far
as he went, Reichert worked with exemplary accuracy, and
this renders his research valuable.
The ovum in question was a flattened sphere, with a
short diameter of 3*3 mm. and an equatorial diameter of
5-5 mm. ; smooth around both poles, and with a marginal
or equatorial zone of villi separating the two smooth areas.
Fig. 1. — Reichebt"s Ovum. Two views engraved from the original plate.
The smaller and flatter of these two areas faced the uterine
wall and bore on its inner surface (i. e., within the ovum) a
small accumulation of rounded cells. The opposite area
was more convex. The villi were short (0-2 mm.), thick
cylinders, with rounded ends and no branches. The walls
of the vesicle consisted only of epithelium, which also
formed the simple hollow villi. The contents of the vesicle
were: 1. The inner cell-mass, lying, as before mentioned, at
one pole. 2. A network of threads, apparently the result of
coagulation of the contained fluid, for no nuclei were found
in it. Kollmann (7, 294) thinks that Reichert's ovum
must have had really two layers forming the vesicular walls
— an inner one of mesoderm (young connective tissue), and
an outer one of true epithelium ; further, that the true
epithelium had been lost, and that only the connective tissue
remained, which Reichert mistook for epithelium. This
supposition is, I think, not probable. Reichert's ovum is,
presumably, younger than any other hitherto described, and
may well have been in the stage before mesoderm had grown
over the chorion. The villi are described as hollow by
Reichert — a statement not compatible with the supposition
that he mistook a solid core of mesoderm for the hollow
shell of ectoderm. Indeed, it is probable that the young
villi contain no mesoderm at first.
Breus's ovum (2) must be considered further advanced
than Reichert's, although the author fixes its age as pre-
sumably ten days. The total diameter of the ovum, includ-
ing the villi, was only 5 mm., and, as the villi were about
1 mm. long, the diameter of the chorionic vesicle must have
been about 3 mm. The villi, some branched, but mostly
without branches, were thick-set, but left one spot bald,
agreeing in this with Jones's ovum (see below). The cho-
rion was smooth on its inner surface, and consisted of (1)
an outer epithelial layer, and (2) an inner connective-tissue
layer, which sent out extensions partly filling the villi. The
ovum contained a thready mass which Breus thinks was
probably a product of coagulation, and an inner cell-mass
about 1 mm. long and 0-5 mm. wide. The presence of villi
Atgtmt 22, 1885.] MINOT: THE EARLY STAGES OF HUMAN DEVELOPMENT.
199
and the existence of the inesodermic layer of the chorion,
contrasted with the absence of any embryonic structure,
led Breus to consider his ovum abnormal. But it is rather
the contrary conclusion we must draw, since all our knowl-
edge points to the deduction that, as compared with the
embryo, the development of the chorion is very precocious
in mammalia. I deem it therefore probable that Breus's
ovum was normal.
Wharton Jones (3) long ago described briefly a human
ovum the chorion of which measures in his figure (said to
be natural size) 6 by 4 mm.
The following is all that can be gathered from Jones's
description : The ovum was already covered by the decidua,
and bore shaggy villi on the side toward the uterus, while
the other side was bald. " The whole cavity of the chorion
was filled with a fine gelatinous cellular * tissue, imbedded
in which, toward one extremity of the ovum, was a small
round body ; it was evidently the vesicular blastoderma.
On being taken out and examined under the microscope, it
presented the same friable, globular structure found in the
vesicular blastoderma of the rabbit in the preceding obser-
vation. There was no vitellary membrane to be seen." To
judge from the minute figure given, the villi were already
branched ; in Reichert's ovum they were still simple.
Ahlfeld's ovum (4) represents, perhaps, the same age as
Jones's, but he does not give its diameter, which appears,
from incidental references, to have been about 5 mm. The
author's description is not exhaustive by any means, but he
mentions two points of great interest — first, the presence
of a layer of connective tissue (mesoderm) underneath the
chorionic epithelium, and extending into, but only partiallly
filling, the villi of the chorion ; second, the character of the
villi, which are slightly branched and are constricted at the
base; only their tips touched the surface of the decidua
(reflexa and serotina). He also states that the epithelium
of the villi precedes in its growth the connective tissue.
This ovum was supposed to be fourteen to sixteen days
old (?). Owing to an accident, no observations of its inter-
nal contents were made.
Beigel's ovum (5), of which he maintains that it is the
third smallest known, is, if we may judge from his plate,
certainly abnormal to an extreme degree. I hold it to be a
malformed ovum of the fifth or sixth week. The ovum de-
scribed by Beigel and Lowe (6) is of an even more ques-
tionable character. Moreover, their account is considered
by Breus and Ahlfeld to be very inaccurate. It is note-
worthy that Beigel and Lowe have also noticed the early
presence of the mesoderm under the chorionic epithelium.
Lowe (6 A) defends himself against Ahlfeld's attack, and in-
sists, with justice, upon the presence of connective tissue on
the inside of the chorion in ova of the second and third week.
Kollmann's memoir (7) is by far the most valuable which
has hitherto appeared upon the structure of very young
human ova. He describes two ova, a and b, both preserved
in the anatomical collection at Basle. Ovum a had been
placed in glycerin and water, which preserved the form of
* This was written in 1837. " Cellular," of course, does not refer
to cells in the sense of the term as used in modern histology.
the specimen but ruined it histologically ; nothing was made
out as to the contents of the chorionic vesicle. The vesicle
itself measured 5 "5 by 4*5 mm., and, therefore, was slightly
flattened. This measure does not include the villi, which
were from 1 to 1*2 mm. long, and repeatedly branched.
Ovum b, 5 -5 mm. in diameter, was well preserved in alco-
hol; the villi were somewhat branched; the contents of the
ovum were lost. On the other hand, the uterus belonging
to this ovum was also preserved, and forms the basis of a
very valuable description of the uterus in early pregnancy,
to which I hope to recur on another occasion.
Kollmann's two ova are both much more advanced than
those of Reichert, Breus, and Jones, as is shown by their
greater size and the branching of the villi. It is a matter
of profound regret that only the chorion was left, but, for-
tunately, Kollmann has taken good advantage of his oppor-
tunity. His paper also gives an excellent critical analysis
of nearly all the previous literature.
He points out that the two primitive layers of the
chorion are probably normally present at this age. The
chorion of his ova, he says, consists of " einer Lage jugend-
lichen, embryonalen Bindegewebes, das zahlreiche Rund- und
Spindelzellen enthalt, und das bedeckt wird von einer ein-
fachen Lage platter Zellen " (p. 293). He then passes the
literature in review and insists strongly upon the fact that
the two layers have been distinguished in nearly all the
very young human ova known except Reichert's. Koll-
mann, therefore, as was mentioned above, questions, I
think, without sufficient foundation, the accuracy of Reich-
ert's account. Concerning the connective-tissue layer Koll-
mann says but little. As regards the epithelium, he points
out that the nuclei occupy a basal position, so that the
outer parts of the cells form a granular stratum, which some
authors have considered a distinct membrane. The author
supposes this granular stratum to become the cuticula de-
scribed in later stages. Jassinsky (9) has given the extra-
ordinary name of tunica propria to this cuticula — extraordi-
nary because "tunica propria" is used technically to desig-
nate the connective-tissue layer upon which an epithelium
rests, and never for an external cuticula. For his supposi-
tion Kollmann gives the reason that in an ovum of four
weeks he found that the layer had become thinner, more
resistant, and less granular — in short, had assumed some-
thing of a cuticular character.
Finally, Kollmann adds (p. 297, ff.) observations on the
growth of the villi in ova of the fourth week. The out-
growth of branches is very rapid and occurs with every
degree of participation of the connective tissue. There are
two extremes : 1. A bud, consisting wholly of epithelium,
which may stretch out into a process with a long, thin pelli-
cle and a thickened end, the whole remaining until it lias
become quite large without any connective tissue. 2. A
thick bud with a well-developed core of connective tissue ;
such a bud probably grows out as a nearly cylindrical
branch. Between these two extremes every intermediate
state can be found. The various forms of growing branches
may lie close together. Probably this complex mode of
growth persists in older villi, which would explain the mul-
tiplicity of forms in the villous branches
200
RUSSELL: PROFESSIONAL ETHICS.
[N. Y. Med. Joub.,
Schwabe (9) has described an ovum which he considers
thirteen to fifteen days old, but he is certainly mistaken,
since both the data he gives as to the age and his account
of the embryo sbow that it is more advanced, and belongs
distinctly in the third week.
In connection with Kollmann's observations we must
notice those of Orth (10), who has shown that at all ages,
even at full term, the villi of the chorion in the ])lacenta
have epithelial buds, which are at first hollow and are after-
ward filled up with a vascularized ingrowth of connective
tissue. Apropos of this observation Orth discusses Boll's
theory of growth, making the point that in this case the
shaping of the parts depends primarily upon the growth of
the epithelium. Boll had maintained as a general principle
that in the development of organs the shaping is dependent
on the co-operation of the epithelial and connective tissues.
Against Jassinsky (9) Orth observes that the epithelium
covering the chorionic villi has only a single layer. There
can be little doubt that Jassinsky was in error in stating
that at certain stages the villi are covered with two epithe-
lia, one right over the other. This mistake agrees with the
false notion that the villi are covered by maternal tissue,
for it might be assumed that one epithelial layer was de-
rived from the uterus. All the best observers agree that
the villi have only a single layer, the chorionic epithelium,
on their surface. It is easy to verify this observation.
Summary. — From the preceding review the following
conclusions may be drawn : The result of segmentation of
the human ovum is the production, by the twelfth or thir-
teenth day, of a rounded sac of epithelium, three to four
mm. in diameter ; at one point there lies against the inside
of the vesicle a little accumulation of rounded cells, which,
from analogy with the ova of mammals, must be considered
as marking the germinal area out of which the embryo is to
be formed. The epithelial sac, to which the name of
chorionic vesicle may also be applied, bears an equatorial
zone of short villi. This stage is represented by Reichert's
ovum, Fig. 1.
In the next stage the villi have spread over the germi-
nal area and have become slightly branched ; the villi next
appear over the opposite pole of the ovum and rapidly in-
crease their length and ramifications. The germinal area
faces the uterine wall (Jones's ovum).
By the time villi are present over the whole vesicle
there is probably always a layer of connective tissue under-
lying the epithelium (Breus, Ahlfeld, Lowe, etc.), but no
embryonic structures have been recognized. The ova of
twelve to fourteen days are already completely inclosed by
the decidua (reflexa and serotina) ; only the tips of the villi
adhere to, or are even in contact with, the decidua; this is
the only connection between the maternal and foetal tissue,
for neither does the uterine mucosa grow in between the
villi, nor do the villi penetrate the cavities of the uterine
glands.
The epithelium of the chorion and villi is only imper-
fectly marked with boundaries for the single cells ; its nuclei
all occupy a basal position, leaving a distinct outer layer,
often mistaken for a separate structure. The epithelium
forms buds, which become branches of the villi. These
buds may grow out to a considerable size without connect-
ive tissue (hollow villi), or the connective tissue may pene-
trate into them from the start (solid villi).
The human ovum, then, is remarkable for its precocious
development of the chorion, both as regards the villi and
the connective tissue or mesodermic layer, and for its early
complete encapsulation by the decidua. All these events
(according to the scanty observations yet made) precede
the appearance of the embryo. It is also noteworthy that
the villi are first developed around the equator, next over
the germinal area pole, and, last, over the area of the oppo-
site pole.
LITERATURE.
1. Reichert, C. B. (1873). Beschreibung einer fruh-
zeitigen menschlichen Frucht imblaschenformigen Bildungs-
zustande nebst vergleichenden Untersuchungen ueber die
blaschenformigen Friichte der Saugethiere und des Mensch-
en. " Abh. Akad. Wiss. Berlin," 1873, p. 92. Taf. i-v.
2. Breus, Karl (1877). Ueber ein menschliches Ei
aus der zweiten Woche der Graviditat. " Wiener med.
Wochenschrift," 1877, 502-504.
3. Jones, Thomas Wharton (1837). On the First
Changes in the Ova of Mammifera in Consequence of Im-
pregnation, and on the Mode of Origin of the Chorion.
(Observation 5, p. 341, describes briefly a young human
ovum of the third (?) week.) "Phil. Trans. R. S. London,"
1837, 339-345. PI. xvi.
4. Ahlfeld, Fr. (1878). Beschreibung eines sehr
kleinen menschlichen Eies. " Arch. f. Gynakologie," xiii,
241-248. Taf. vii.
5. Beigel (1878). Der drittkleinste bisher bekannte
menschliche Embryo. " Arch. f. Gynakologie," xiii, 437-
439. Taf. xiii.
6. Beigel und Lowe (1877). Beschreibung eines
menschlichen Eichens aus der zweiten bis dritten Woche
der Schwangerschaft. " Arch. f. Gynakologie," xii. Hft. 3.
6 a. Lowe, Ludwig (1879). In Sachen der Eihaute
jiingster menschlicher Eier. "Arch. f. Gynak.," xiv, 190-
196.
7. Kollmann, J. (1879). Die menschlichen Eier von
6 mm. Grosse. " Arch. Anat. Physiol., Anat, Abth.," 1879,
279-311. Taf. xii, xiii.
8. Schwabe, Gustav (1879). Eine fruhzeitige mensch-
liche Frucht. " Zeitschr. f. Geburtsk. u. Gyn.," iv, 196.
9. Jassinsky, P. (1867). Zur Lehre ueber die Structur
der Placenta. Virchow's " Archiv," xl, 341-352. Taf. iii.
10. Orth, J. (1877). Das Wachsthum der Placenta
fetalis und Boll's Prinzip des Wachsthums. " Zeitschr. f.
Geburtsh. u. Gyn.," ii, 9-21. Taf. iii.
PROFESSIONAL ETHICS*
By the Hon. W. H. H. RUSSELL.
Mr. President and Gentlemen : When our efficient
and ever-zealous brother, Dr. Brill, notified me a few days
ago that at this meeting you would expect a paper from
me, the inquiry at once arose in my mind as to what theme
* Read before the Society of Medical Jurisprudence and State Medi-
cine, May 14, 1886.
August 22, 1885.J
would best suit the complex mental equilibrium of the mem-
bers of this association (the term complex is good, because
Southworth well observes, " The parable of the wedding
supper comprehends in it the whole complex of all the
blessings and privileges of the Gospel "). So the complex
mental equilibrium of the professions of medicine and law
comprehends all there is of worth and glory in those two
professions to the outer world, when practically exemplified.
We looked over the subjects and titles of the previous pro-
ductions, and came to the conclusion that perhaps a few
thoughts upon Professional Ethics might interest and enter-
tain you, and, perchance, awaken new and more vigorous
interest in the objects of this and kindred associations.
And, after listening to the very able and eloquent address
of Parke Godwin the other evening at Association Hall,
upon the problems of social science, under the auspices of
the " Institute of Social Science'''' (of which he is president),
I am pleased with this opportunity of offering a few com-
ments that may at least provoke a discussion on your part
and engender a spirit of strict professional pride in the
<rreat callings in which the members of this society are bat-
tling the stern realities of life.
On the 3d of March, 1883, this society was regularly
incorporated under the laws of the State, under the name
and title, " The Society of Medical Jurisprudence and State
Medicine" with this significant declaration in its charter
and by-laws : " The object of this society shall be the inves-
tigation, study, and advancement of the science of medical
jurisprudence and State medicine, and the attainment of a
higher standard of medical expert testimony.'1'1
A most laudable purpose, with a most glaring public
necessity for the complete success of its mission.
How can its objects be fully attained ? is the question
which should most interest its founders and members. As
this world goes to-day, most men are actuated by motives
of gain, either of a financial or popular nature, and the im-
patient push of business life leaves little inclination or time
for calm, reflective, philosophic thought or action. And
the standard nowadays by which men are gauged is the
accumulation and possession of wealth and the display
thereof. Money is the sovereign power before the golden
throne of which men and women of genius, talent, and
culture must bow, as if involuntarily drawn by her magical
wand.
Success in money getting and saving is the best evi-
dence of merit and success, say the neophytes of popular
praise and ambition, and the man who clips his coupons
and counts his thousands is courted and favored, while the
brain worker of true merit struggles along the rugged jour-
ney, necessarily content with a bare pittance of subsistence.
Parke Godwin's theories and suggestions as to the solution
of the difficult problems of social science were very clever
and plausible, and, if that learned and cultured gentleman can
make his eloquent sayings and doctrines practiced through
the medium of the organization which he inaugurated on
the evening of the 7th inst. by his very able and interesting
address, he is indeed one of the greatest philosophers and
philanthropists of the nineteenth century.
All reforms and great remedies must be founded in the
201
proper education of the people as a mass, and all praise and
success to his noble enterprise.
Many years ago the " American Medical Association "
was organized and founded in the old city of Philadelphia
(patriotically known as the cradle of American indepen-
dence), and, from the various " codes " of " medical
ethics " down to that of most recent date, we would natu-
rally infer that the standard of professional ethics in that
learned profession is fully established and rec< gnized. Sec-
tion 1, Article I (under the caption), " Of the Duties of
Physicians to Each Other and to the Profession at Large, and
Duties for the Support of Professional Character'"1 third
edition, 1882, provides as follows: " Every individual on
entering the profession, as he becomes thereby entitled to all
its privileges and immunities, incurs an obligation to exert
his best abilities to maintain its dignity and honor, to exalt its
standing, and to extend the bounds of its usefulness . . . ." If
that provision was practiced and enforced, there would be
no quacks, no charlatans, and no frauds in this great sci-
ence, which ^Esculapius, long centuries ago, would have
made the pride and glory of his age and the generations to
follow.
On July 1, 1878, some of the most eminent lawyers in
this country — William M. Evarts, of New York, Benjamin
H. Bristow, of Kentucky, George Hoadlcy, of Ohio, Henry
Hitchcock, of Missouri, Charlton Hunt, of Louisiana, Rich-
ard D. Hubbard, of Connecticut, Alexander R. Lawton, of
Georgia, Richard C. McMurtree, of Pennsylvania, Stanley
Matthews, of Ohio, E. J. Phelps, of Vermont, John K.
Porter, of New York, Lyman Trumbull, of Rlinois, Charles
R. Train, of Massachusetts, and J. Randolph Tucker, of
Virginia — issued a call to distinguished members of the Bar
to meet at Saratoga in August of that year for the purpose
of organizing an " American Bar Association.''1
The meeting was held, and a constitution and by-laws
were adopted, with the name and object declared, as follows :
Article I. liThis Association shall be known as '■The
American Bar Association.' Its object shall be to advance
the science of jurisprudence, promote the administration of
justice and uniformity of legislation throughout the Union,
uphold the honor of the profession of the law, and encourage
cordial intercourse among the members of the American Bar."
Thus, in a national sense, these two professions have
proclaimed, by organic provisions, the promotion of juris-
prudence and a higher standard of professional honor and
ethics in the United States. State and local organizations
of the same character have been established in every section
of the Union, and there can be no question but that, if the
objects as declared were carried into effect, we would to day
behold a very different status of professional life and stand-
ing in every community. By organized unity of purpose
and action, men and people may be educated to recognize
the force of discipline and the worth of true merit and
character.
For instance, if in the profession of the clergy there
could be found the high-toned elements of courteous and
genial deportment, in that all their efforts were in har-
mony with one great purpose, and that the unbounded hap-
piness of the human family, irrespective of any particular
RUSSELL: PROFESSIONAL ETHICS.
202
RUSSELL:
PROFESSIONAL ETHICS.
[N. Y. Med. Jodh.,
creed or sect, what a halo of glory would mantle every tem-
ple of worship that lifts its spires heavenward ! If every
student, scholar, and expert in medicine were to practice
the profession with one common purpose, and that the true
relief of suffering humanity, what a world of pleasure this
might be ! And if every lawyer and disciple of the great
Blackstone, Story, and Kent were to exemplify the true
principles of law, equity, and justice, what a magnificent
system of jurisprudence we would have in this country !
Government, society, and religion would then triunize and
glow more beautiful than the prospective electric light
which is to gleam and glitter from that noble gift of warm-
hearted France which is soon to ornament our harbor as
the ideal statue of "Liberty enlightening the World?"1
Professional ethics, if developed, practiced, and encour-
aged in America, can do more for the future perpetuity of
our republic and institutions than any other element in the
social fabric.
Necessarily the toilers in the other vocations of life look
up to the professions for examples of true manly character,
and in the three great professions of divinity, law, and medi-
cine you may find the framers of laws, customs, and usages
of society. The moral maxims and the elements of true
civilization are more or less formulated, crystallized, and
promulgated from these three channels of intersocial and
state life. The records of the National Congress of the
State and municipal governments show that in the legisla-
tion of the country they have been the foremost workers in
reforms and great measures (i. e., the true ones of the pro-
fessions), and they have always been found upon the side
of good government as agaiost the false ones of their re-
spective callings.
During the fourteenth century, nearly five hundred years
ago, the profession of the law was guarded by special acts
of Parliament, which provided, among other prerequisites of
admission to the Bar, that none but 11 good and virtuous"
men, " learned and of good fame," should be sworn as attor-
neys, and that before their names could be put upon the
roll they should be examined by the justices; and that, 11 if
any such attorney be found in any default of record or other-
wise, he shall forswear the court and never after be received
to make any suit in the courts.'1''
If such a law was in force in this country to-day, what
a weeding out there would be ! In those days the employ-
ment of attorneys was pecuniary, i. e., they were entitled to
fees, while that of barristers was honorary. Attorneys
could recover their fees in assumpsit, while barristers could
claim nothing, at law or in equity. Attorneys were liable
for neglect of ordinary care and diligence of their clients'
interests.
The attorney could confer directly with his client; the
barrister could not. The attorney prepared the facts and
the brief, and the barrister took charge of the cause in
court; and to a certain extent the same system prevails in
England to-day. This system has never been introduced
into this country, although Judge Story, who was the ex-
emplar of the exalted functions of the Circuit Court of the
United States for the little State of New Hampshire, did
confer the degree of Sergeant-at-law upon Jerre Mason and
Judge Smith, and that of Barrister-at-law upon Daniel Web-
ster.
It must be admitted, by those familiar with the system
of English jurisprudence, that to-day there is greater pro-
tection to life, liberty, and property in Great Britain than
any other section of the civilized world, and that an English
subject is protected in all quarters of the globe. I remem-
ber well, while in London in 1871, the impressions then
made while in the Mansion Court of that great city. Two
hoys, about twelve and fourteen years of age, were called up
before the magistrate for the violation of some city ordi-
nance ; the magistrate was a man of about fifty years of
age, and looked the personification of a human judge. Af-
ter the officer who had arrested the boys had given his
evidence, the justice told the boys to stand up, and then
asked them what they were doing when the officer had
found them. The oldest boy replied that they had started
for the country, and had got that far, and, not having any
money, had crawled into the boxes to sleep during the
night. The justice, who was able at a glance to distinguish
between a bad boy and an unfortunate one, said : " Boys,
go into the country and stay there ; work in the fields, and
stay away from the great city " ; and, turning to the clerk
of the court, he said : " Mr. Clerk, give those boys a shilling
apiece"; and then, looking at the officer who had arrested
them, he said : " And you, Mr. Officer, see them well on their
way to the country before you leave them."
I wish some of our American magistrates could have
seen the expressions upon those boys' faces as they left that
court-room.
It was worthy of the finest touch upon canvas and the
most exquisite and delicate chipping of the greatest sculptor.
If our court-houses were, indeed, temples of justice, what a
sublimity there would be in the practice and magistracy of
the law ! If the high-minded and good men of the learned
professions of medicine and law, and I may add the minis-
try, would strike hands and say there shall be a higher
standard of professional ethics in the United States, we
would not read of such scenes as occurred the other
morning in one of the courts of this city, where the justice
from the bench, in open court, rebuked a pseudo medical
expert by saying : " The city ought to put another such a
doctor upon the pay-roll."
NUMBER OF LAWYERS, MINISTERS, AND DOCTORS IN THE
UNITED STATES.
It may be of interest to know the proportions of the
great professions in this country to each other and the com-
munity at large.
In 1850 there were in the United States 23,939 law-
yers, 26,842 clergymen, and 40,564 doctors. In 1880
there were 64,137 lawyers, 64,698 clergymen, and 85,671
doctors — in all, 214,506. In the thirty years from 1850
to 1880 the professions more than doubled in membership.
In 1850 there was one lawyer to 964 people, one clergyman
to 864, and one doctor to 569. In 1880, one lawyer to 782
people, one clergyman to 775, and one doctor to 585.
Of these 214,506 professional brain workers in 1880,
there were of the 64,137 lawyers 75 females, of the 64,698
August 22, 1885.J
RUSSELL: PROFESSIONAL ETEICS.
203
clergy 165 females, and of the 85,671 doctors 2,432 were
females ; 64. of the 75 female lawyers were under sixty years
of age and 11 over; 140 of the female clergy were from
sixteen to sixty years of age and 25 over ; 2,268 of the fe-
male doctors were between sixteen and sixty years of age
and 164 over. Of all the three professions, 193,294 were
under sixty, and 21,212 over sixty years of age. If the
pro rata increase of population continues in the next cent-
ury as in the past, there will then be a population of over
200,000,000, and over 200,000 lawyers, ministers, and doc-
tors, in proportion as before.
Cast your horoscope of thought over the progress in this
country for a hundred years to come and, if possible, calcu-
late the effect upon the people at large if every lawyer,
doctor, and minister would be true to his calling. If there
was a code of ethics with the clergymen of this country
which would harmonize with the great doctrines taught by
the Founder of their faith, before whom it is said the wise
men of the East bowed with reverence and consecrated the
lowly manger as the cradle of Christian civilization, there
would be no occasion for a congress of churches.
The true and noble-hearted Dr. Howard Crosby, of this
city, in his excellent paper before the Congress of Churches
at Hartford, on the 11th inst. (as reported in the " Herald"
of the 12th), gave three substantial reasons why a code of
ethics should be established among the ministry of this
country ; and, if his suggestions were adopted by every fair-
minded worker in that exalted profession, America might
become the imperial jewel in the progress of Christian civili-
zation. All praise to his philanthropic efforts.
If in the profession of the law there was a well-estab-
lished, recognized code of legal ethics, there would be no
shysters and scapegoats of unscrupulous villainy. For, as
England's great premier, Mr. Gladstone, well said, in a re-
cent address : " Considered as a mental training, the profes-
sion of the Bar is probably of its kind the most perfect and
thorough of all professions."
If, as a profession, it is followed and practiced in the
true spirit of the law and of justice, every conscientious
lawyer must be true to the State, the people, his clients,
and his cause. He must be as the great Blackstone (the
father of the common law) once poetically wrote :
" To Virtue, and her friends, a friend,
Still may my voice the weak defend.
Ne'er may my prostituted tongue
Protect the oppressor in his wrong,
Nor wrest the spirit of the laws
To satisfy the villain's cause."
And yet it is the most abused of all professions, and
people are apt to think that a smart lawyer must necessarily
be unscrupulous, that his conscience must be as plastic as a
rubber band, to contract or expand as the case requires ;
and history affords some latitude for such insinuations.
It is said that when Peter the Great visited Westminster
he saw many oddly appareled persons, whom, upon inquiry,
he learned were lawyers, and he was so amazed that he ex-
claimed: "What, all these lawyers? I had but two in all
my dominion, one of whom I hung, and I intend to hang
the other as soon as I get home." It is not recorded that
he kept his word, and, in fact, it is seldom if ever that you
read or hear of a lawyer being hung, while it is not an un-
common event of late years to read of a doctor being exe-
cuted. It should not be forgotten that the cradle of the
resurrection was a lawyer's grave, and that a lawyer was the
only man in all Jerusalem who had the moral courage to
approach Pilate and demand that the body of the Saviour
of mankind should be taken down from between the thief
and the robber and placed in his own sepulchre. And, on
another occasion, it was a lawyer who, by his undaunted
courage and eloquent appeal, saved the Disciples from being
set upon by a mob and slain, and thus the greatest authors
of the New Testament were saved.
Shakespeare presents us with the ideal advocate in the
play of the " Merchant of Venice," and Dickens, the great-
est characterizer of later years, gives us his typical jurist in
the personage of the " little judge " who presided in the
famous case of Bardell vs. Pickwick, who was so exact in
the rigor and spirit of the law that he would not excuse the
chemist whose assistant did not know the difference between
oxalic acid and Epsom salts. If some of the druggists of to-
day would remember that fact there would be less danger
of poison from drugs.
Nice and elegant distinctions should not be made to the
detriment of the profession at large — as in the instance of
Prof. Huxley, who relates of a distinguished surgeon who
(being irritated by the pretensions of some physicians) was
asked if he meant to bring up his boy to his own calling,
replied : " No, my son is such a fool I mean to make a phy-
sician of him.'''' Or as, on another occasion, two gentlemen
were discussing the old proverb, " At forty a man must be
either a fool or a physician,'1'' when the other replied :
" True, but don't you think he may be both ? " Or that of
the Irish physician who, while dining with Theodore Hook
(who remarked : " I should like to place over my door an
inscription, either in Latin or Greek, borrowed from one
of the great authors "), at once suggested, " Give Italian
the preference ; nothing can equal that verse of Dante's,
'Abandon hope, all ye who enter here.'1'''' Sir Astley Cooper,
the great surgeon, openly discredited the science of medi-
cine " as one founded upon conjecture and built upon mur-
der.''1 Or as the German wit said : " Physic always does good,
if not to the patient, at least to the apothecary." And in
France the young medical graduate is spoken of as " licensed
to kill."
When a man dies suddenly, without having been attend-
ed by a doctor (says a humorous writer), the coroner has
to be called in and an inquest held to ascertain the cause
of death ; but, he adds, when he dies after having been at-
tended by a doctor, then everybody knows why he died, and
an inquest is not necessary.
Or as a German paper has it in humorous dialogue shape,
the child going to inform the pastor of the death of it.
father :
Child. — " Herr Pastor, my mother sends me to tell yon
that father died to-night."
Pastor. — " Did you send round for the doctor ? "
Child.—" No, Herr Pastor, father died of himself."
And again as illustrated by the nurse in the hospital
RUSSELL: PROFESSIONAL ETHICS.
[N. Y. Med. Joch.,
in reporting to the physician in the morning: " Six of the
fever patients have died, sir."
" Why, I wrote prescriptions for seven," mused the
doctor as he passed on into another ward.
" Yes," said the faithful nurse, " but one of them
wouldn't take his."
In Russia they say the doctor seldom takes physic, and
in Spain proverbial aphorisms are numerous, such as " The
earth covers the mistakes of the physician," " The doctor
is to be feared more than the disease," " Physic is a curse
to humanity," " It is God that cures, the doctor gets the
money." And one of the most common sayings in Portu-
gal and Spain is, " If you have a friend who is a doctor,
take off your hat to him and send him to the house of your
enemy."
Or like one of our doctors who upbraided some of the
workmen the other morning for the careless manner in
which they were replacing the earth over the gas and tele-
phone pipes in the city, one of them looked up and good-
naturedly said : "Faith, Doctor, ours are not the only mistakes
the earth covers."
These instances are recited for the purpose of showing
that the doctors arc subject to frequent abuse and unjust
insinuations. If the prescriptions and remedies cure, their
services are cheerfully rewarded ; but if the patient lan-
guishes and dies, then follow too often dissatisfaction and
unjust abuse. Some other doctor may say that there was
not a proper diagnosis, and that from his prognosis the
patient might have lived. Professional ethics forbids such
deportment, and we believe that if the medical colleges and
schools would establish one common medical curriculum,
with fixed grades of graduation, and then the profession at
large would enforce a uniform code of medical ethics, there
would be better doctors, physicians, and experts, and less
abuse. If the colleges, schools, and societies unite and
work together, and the doctors, as a profession, regulate the
ethics of practice, you can secure laws in every State that
will protect the people from imposition and the profession
from quacks and renegades.
An eminent English author, Mr. Palgrave, in his excel-
lent work, " Rise and Progress of the English Common-
wealth," says : " Man never begins by introducing any law
which is entirely unreasonable, but he frequently allows a
law to degenerate into folly by obstinately retaining it
after it has outlived its application."
And Goethe in " Faust " thus poetically exclaims :
M Laws, like inherited disease, descend ;
They slyly wind their way from age to age,
And glide, almost unseen, from place to place.
Reason to nonsense grows, a benefit to plague.
Woe unto thee, that thou a grandson art
Of inborn law, to which each man has right ;
Of that unfortunately there is no question."
It can not be doubted or questioned but that there is
need of great reforms in law and medicine. And, if the
members of those two professions were guided and governed
by well-established codes of ethics, they could accomplish
any reforms they might wish.
And then we should have medico-legal societies that
would produce experts who would be ornaments to the pro-
fessions and the homes of our country, and an honor to the
age. Can we have them ? Yes !
The ideal lawyer, as presented by that distinguished
Nestor of the New York Bar, David Dudley Field (in his
recent address before the law students of Dalhousie College,
at Halifax), " is one who is master of the laws of his own
country and a student of other laws as they may serve to
elucidate or improve his own ; a faithful adviser, a fearless
defender, prompt to make use of his learning and opportuni-
ties, not only for the protection of his own clients, but for the
improvement of the laws themselves, whenever he finds them
the instruments of injustice."
And may we not look beyond the disc of his immediate
orbit and say, in addition, that the ideal lawyer is he who,
while faithful to the principles of his profession, does not
delay justice by unfounded objections, nor increase the ex-
pense of litigation by imposing unjust costs and hindrances?
The present system of costs in this State is one of the
most iniquitous ever tolerated in any civilized community ;
it is in many respects extortion, and almost robbery. It
takes from the pockets of the unsuccessful litigant money —
not to defray the necessary and legitimate expenses of the
court, but to line the pockets of the counsel of the prevail-
ing party ; and the Courts have recently held that the attor-
ney has a lien upon the costs as against all equitable offsets
or counter-claims. The lawyer should not be entitled to
the costs of the case; they should be light and go into the
county treasury for the necessary expenses of the courts, in
paying the salary of its officers, and the jury-fees. The
lawyer should, like every other citizen, make his contract
with his client, and stand upon that contract without the aid
of the Courts and the machinery of justice to facilitate him
in making the costs unjust and burdensome to the litigant
and citizen.
Some of you may have noticed the other day, in one of
our most enterprising papers, a statement to the effect that
a citizen who brought suit on a §400 claim realized $190
on the property sold under execution, and thereby became
liable for over $1,200 costs which had accrued in the case
during the process of litigation. A code of legal ethics
would not permit of such infractions upon the fundamental
principles of justice.
The very able paper by Judge Hull upon expert testi-
mony, read before this society, clearly illustrated the neces-
sity of concerted action in the two professions for complete
codes of professional ethics.
And the somewhat noted will case now under investi-
gation in the Surrogate's Court reveals the fact that a pre-
tentious lawyer, who, as reported, was a pawnbroker a few
years ago, wants $3,500 for the original draft of a will, and
$3,500 for attending the contestant in a police court. And
the expert in the case, on Tuesday last, when asked by a
distinguished substituted counsel if he had prescribed for
mania, said, " Yes ; I don't remember what I prescribed,
how much I prescribed, or anything about it." And then,
being asked if he was a mad doctor, replied : " No more
than a horse-chestnut is a chestnut horse."
A high standard of professional ethics in the professions
August 22, 1885. J
R TTSSEL L: PRO FESSIONA L • ETHICS.
205
of law and medicine, enforced by such organizations as this,
and the Bar' and medical associations of the country, would
bring about a better class of experts and a more honorable
and respected status of the professions.
Lord Mansfield, one of the brightest and greatest of
England's jurists, said : " Jurisprudence is a rational science,
founded upon the universal principles of moral rectitude, but
modified by habit and authority."
What we need to-day in this country is reform in legal
jurisprudence and reform in medical jurisprudence, so that
when a man dies, if he is fortunate enough to possess mill-
ions, his life and his memory may not be shadowed by the
unlicensed latitude of unscrupulous lawyers and doctors,
who do not comprehend the domain of decency nor under-
stand the first principles of medico-legal jurisprudence.
We could then say, in fact, The true physician is he who
has a proper conception and estimation of the real character
of his profession ; whose intellectual and moral fitness give
him weight, standing, and character in the consideration
and estimation of society and the public at large. He is
to a certain extent the servant of the community in which
he resides ; he is subject to the call of the sick and suffer-
ing in the humblest and lowest walks of life, and even the
bedside of the most penitent and worldly may command
his presence, his skill, and aid. From the lowly, languish-
ing couch of the weary, wanton, unfortunate waif of society
to the sacred sanctum of marital purity he will be sum-
moned at all hours of the day and night to relieve and alle-
viate the pains of suffering humanity.
His privileges and powers for good or for evil are great ;
in fact, no other profession, calling, or vocation in this life
occupies such a delicate relation to the human family.
In every household, at every fireside and in every cham-
ber, the good and true physician is a welcome visitor ; his
genial face, his kind and courteous treatment, and his manly
deportment will always secure for him the blessings of the
domestic circle. The domain of the sacred home is the
empire of his glory.
The fond and affectionate mother, in that tenderest and
most delicate of human reality, will intrust to him not only
her own safety and welfare, but that of her offspring (the
brightest jewel of ennobled womanhood) ; and then, in after
years, when the cares of life are over and the mystical
spark is about to leave the earthly tenement of frail mor-
tality, the family physician will be called upon in the last
moments to close the once beaming eyes that were the win-
dows of the soul, and impart the information to the weep-
ing children and friends that death is triumphant beyond
his skill or power; and thus, from the cradle to the thresh-
old of eternity, the true physician becomes the ministering
angel of wasting mortality. He can not overestimate the
responsibilities of his profession as physician and humani-
tarian. The American nation proper are greatly in need of
such medical advisers. Fashionable society, in the maud-
lin light of popular display, is pressing out the fountain-
life of true maternity and healthy progeny.
Conceptivc preventives and abnormal deliveries are of
too frequent use and occurrence for healthy national growth
and perpetuity. If the family can be limited to one or
two children, and perhaps none at all, elegant society is de-
lighted and satisfied.
Child-6«V/A and nursing have become the dread and hor-
ror of the votaries of fickle fortune, whose gods and god-
desses live only in the present.
The great physician should and will stand forth in the
true light of the science of his profession as the promoter
of health and happiness, and the protector of family life
and professional honor.
The people love justice and fair play, and the lawyers
and doctors who practice with fidelity the great principles
of their profession must be honorable in their relations to
each other and the community at large. As the stars move
in harmony with this world and the planetary systems, and
reflect their light and beauty in the shadows of darkness,
so do the true votaries of these great professions, in their
intercourse and contact with struggling and wasting human-
ity, reflect the light, the glory, and the wisdom of their
callings. And if we could only exclaim,
" Could a man be secure
That his days might endure,
As of old, for a thousand of years ;
What things he might know,
What deeds he might do,
And all without hurry or care ! "
By professional ethics we mean the science of duty as
established and recognized in a system of principles and
rules governing all licensed lawyers and doctors, and en-
forced and respected by high-toned and cultured gentlemen
— a standard of professional honor so sacred and inviolate
that no graduate or regular practitioner will ever presume
or dare to violate it.
Can such a standard be established ? We say Yes ; and
you ask How ? In the profession of the law the courts are
always open and ready to disbar any lawyer who is guilty
of unprofessional conduct; and they can do it by summary
process, as, in a recent case in Chicago, they compelled a
shyster attorney to take down his sign and discontinue his
advertisement of " Divorces obtained with secrecy and dis-
patch." And similar ones have been discontinued in this
city. May I suggest how this can be accomplished in the
medical profession, so that glaring cards in the papers and
distastefal and unprofessional circulars can be stopped and
prohibited ?
If the medical societies will provide in their codes of
ethics that none such shall be recognized in the fraternity,
and then some of the leading physicians of this city and
State prepare a bill to be introduced in the Legislature pro-
viding for a medical commission, with power to sit, hear,
and determine all grievances of that nature, and, in cases of
guilt, to revoke licenses, and that no one shall be permitted
to practice medicine without a license registered in the
County Clerk's office, you will have a complete remedy
against all the ills of abortionists, quacks, and charlatans.
It is the sacred duty of good doctors to sec that such reme-
dies are provided at once.
These are times of needed reforms, and, if the great
professions will inaugurate complete systems, wc may look
for better times in legitimate practice and a higher grade
206
BUXTON: IS EXPERIMENTAL MEDICINE JUSTIFIABLE? [N. Y. Med. Jouh.,
of public morals and professional honor, and, with Hooker,
agree that " of law there can be no less acknowledged
than that her seat is the bosom of God ; her voice the
harmony of the world ; all things in heaven and earth do
her homage; the very least is feeling her care, and the
greatest is not exempt from her power, though angels and
men and creatures of what condition soever, though each in
different sort and manner, yet all with uniform consent ad-
miring her as the mother of their peace and joy."
Such law, properly enacted and wisely administered and
enforced, will bring contentment, prosperity, and happi-
ness.
Lord Brougham, one of England's most eloquent jurists,
in advocating a great reform in her jurisprudence for the
good and benefit of the people, inspiringly said:
" It was the boast of Augustus that he found Rome
of brick and left it of marble ; but how much more glori-
ous will it be for that sovereign who can have it to say
that he found law dear and left it cheap ; found it the patri-
mony of the rich, left it the legacy of the poor ; found it a
sealed book, left it an open page and a living letter ; found
it the two-edged sword of craft and oppression, left it the
staff of honor and the shield of innocence ! "
jVote. — A committee, consisting of Dr. Spitzka, the Hon. William
Barnes, and Dr. McAuliff, was appointed by the society, to take into
consideration the suggestions, and report at the meeting in October.
IS EXPERIMENTAL MEDICINE
JUSTIFIABLE?*
By DUDLEY W. BUXTON, M". D., B. S.,
ASSISTANT TO THE PROFESSOR OF MEDICINE IN UNIVERSITY COLLEGE. LON-
DON ; MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS.
Gentlemen, I think it is. I go further. I say that
medicine, whether it be a science or the empiric's art, is
essentially experimental. This is a proposition I shall seek
to prove to your satisfaction. I should say that some men
reap the benefit, in their daily medical practice, of the ex-
periment of others. They may not know this fact, having
acquired their knowledge by the art of thumb-nail note-
taking, but the fact remains. Some men learn their medi-
cal practice at the bedside. These men experiment.
Some men attempt to reproduce in their physiological
research-rooms phenomena they find in clinical practice,
and then strive to remove the morbid conditions ; or, it may
be, learn how, in the coming time, to protect men, women,
and children from the lethal effects of a dread disease.
These men experiment.
I hope to show you that, as the footsteps of medicine
have traversed the sands of time, they have all along been
guided by the staff of experiment, the light of inductive
research. That staff, indeed, may have bent and grown
warped when its fibers were overtaxed by headlong haste
over rugged paths ; but it is supple, it straightens itself, and
saves the tottering load from falling. That light, too, may
flicker, its luster may grow dim amid the scintillations of
an ignis fatuus which we moderns call quackery, but it
* Read before the Medical Society of University College, London,
March 4, 1885.
shines again bright and steady when it is taken into the
darkness of the unexplored regions of the unknown.
With your permission I will state what I include under
the term " medicine." I will define experiment, and will at-
tempt to formulate the grounds which appear to me, by the
common consent of civilized men, to be taken as sufficient
for justification of an act.
Medicine, in this connection, I take it, implies a knowl-
edge of the
1. Causes of diseases — aetiology.
2. The knowledge of how best to counteract these
causes and so prevent the onset of disease — i. e., state or
preventive medicine.
3. The art of recognizing with what disease we are con-
fronted— i. e., diagnosis.
4. As well as the clear knowledge of the train of symp
toms which will, in due order and course, supervene. It
will be necessary to recognize not only that the disease runs
such a course, and that at one particular time we may an-
ticipate this or that emergency, but it is requisite that we
should know what consequences may accrue from it, and, by
due precaution, obviate the occurrence of the sequela?. This
includes clinical medicine in part.
5. We have yet to include the therapeutic treatment of
disease, a branch of medicine of especial interest to us in
this connection.
6. To anticipate the issue of a dangerous illness is also
the business of medicine as an art. This, the practice of
prognosis, has a most important bearing upon human happi-
ness and prosperity. Such, then, is the scope of the science
and art of medicine.
Experiments undertaken to further any of the aims and
objects I have indicated above will constitute a portion of
my theme to-night, and will have to be passed under your
judgment, that you may say not, Is this or that individual
experiment justifiable ? but, Is the principle of applying the
experimental method to medicine one which we, first as
men, then as practitioners of medicine, can look upon as
right and, in the highest sense of the word, legal ? It is
indeed hard to say what others will allow to constitute
justifiability. It may not, indeed, be difficult to invent a
wordy law, but this, gentlemen, is useless ; old as the days
of Butler was the truth that
" He that complies against his will
Is of the same opinion still."
I submit, then, that, for lack of a more comprehensive
system of ethical morality, we may hold that those acts are
justifiable which tend to promote the well-being of the
greatest number. If a member of the intelligent and much-
be-sat-upon minority claims attention to the sufferings of the
few, with sorrow must I confess that his case is hard but
hopeless. If the majority gain benefits from experimental
medicine, I submit experimental medicine is not only justi-
fiable, but its pursuit is an honorable duty.
Now, gentlemen, may I remind you that my task here
commences? It is incumbent upon me to show that medi-
cine has ever derived advantage from experiment, and, as
practiced to-day, is being, week by week and month by
month, enriched with new facts, established in sound gener
August 22, 1886.]
BUXTON: IS EXPERIMENTAL MEDICINE JUSTIFIABLE?
207
alizations, lopped of mushroom growth of unsound theo-
ries and practices of superstition, and that all this is due to
the experimental method.
And here may I digress ? I would have you to consider
the ultimate uses of watch-springs 1 and block-brakes as
applied to mineral trains.
If the keen-eyed rhetorician, who is, I hope, ready to
belabor my arguments and confute my contentions, should
inquire what possible relation watch-springs and block-
brakes have to experimental medicine, I would answer,
Much in every way. Watch-springs are apt to uncoil with
startling and unpleasing celerity when your escapement is
out of gear, while brakes are used to stop or check progress.
Philosophers tell us that the sum total of human progress is
ever increasing, and men of genius, watch-spring like, hurry
on this mental advance-guard. Here, then, comes into use
the human brake — the Huns, the Vandals of days gone by,
the anti-dissectionists of Vesalius's era, the anti-vaccination-
ists and anti-vivisectionists of the year of grace 1885 — and
enforces upon the pioneers thoroughness of work and readi-
ness in intellectual combat. I regard the noble Attila, the
Hun, and Mr. Hutton as most valuable persons, and daily
return thanks for their institution ? Can one, gentlemen,
conceive any more appalling apparition than that of a man
a century ahead of his neighbors ? Lully only pretended to
transmute copper into gold, but the indiscriminating inhabi-
tants of Africa stoned him. Had he contented himself with
the converse process, how great a demagogue he might have
been !
Medicine has a long history ; it is one which would bear
out my main point of contention were it possible for me to
bring before you its changing scenes and characters. It
would best answer my purpose to permit the story of how
medicine has slowly but surely advanced from the feudal-
dom of mere leechcraft to the epoch of reason which could
produce a Laennec, a Louis, a Virchow, or a Jenner. It is
a far cry from the mystic incantations of the priests of the
Egyptian deity Isis to the systems of medicine which rest
on the shelves of every practitioner of to-day ; and so it will
be impossible for me to do more than indicate a few of the
main advances in medicine which have, as it were, marked
epochs in the history of its philosophy. I will attempt this.
I will strive to set forth how far these advances were due to
the experimental method, and, in conclusion, I hope to lay
before you the proposition which, coming last, is not the
least important part of my argument.
It is difficult for us, who habitually compress into a
meager curriculum of four or five years, the subjects which
are kindred to medicine and surgery, to comprehend how
deeply and inextricably interdependent are these sciences.
It is hard for us to realize that in the old days men spent a
lifetime in mastering those facts in anatomy which nowa-
days scarcely insure a student's passing his examination for
the College of Surgeons.
Physiology, again, in spite of the work of such men as
Vesalius, Servetus, Fabricius, and the long and illustrious
roll of the Padua School, can not be said to have com-
menced until Harvey promulgated in 1619, before the Royal
College of Physicians in London, the result of his experi-
ments made three years anterior, and which proved to dem-
onstration the circulation of the blood.
Comparative anatomy, the most important aid to the
physiological physician, was studied earlier and more fully
than human anatomy. Galen, who, from the pinnacle of
the knowledge obtainable in the second century, could de-
ride — which he did con amore — the mistakes of the
older physicians, learned his anatomy and physiology from
the dissection of apes. Nor is the reason for this far to
seek. The ancients were as opposed to dissection of the
human body as were our forefathers before the passing of
the Anatomy Act, and apes in those days were held of little
worth. Possibly the assent given to the evolution theory
sways, and I think justly, the minds of antivivisectionists of
this generation. It was not long ago that we were asked to
consider how necessary to medicine is physiology. I am
so thorough-going a believer in the absolute indissolubility
of these sciences that I think the medicine of to-day is
either physiology applied or it is quackery. So that if
Galen and Harvey and their following learned their physi-
ology from the story unfolded by experiments, I say these
men used the experimental method to gain knowledge of
the devious paths of medicine. It will at once be said that
none nowadays object to the dissection of the bodies of
defunct dogs and cats, or even of paupers. Provided the
corses of honest men who die well to do, and of criminals,
be respected, scalpel and scissors may run horrid riot as
much as anatomists will. I may not pause to expose the
shallow sophism of this argument. 1 will only say that anat-
omy is tolerated, being preferable to body-snatching, and
that for my purpose I must be allowed to show that experi-
ment, whether upon the cadaver or the living body, is
equally important for a true knowledge of medicine.
Lizars, the well-known anatomist, dedicating to King
George IV, says :
" It is impossible for me, or for any other teacher, in this
department of professional education, not to regret, most
painfully, that, through the increase of certain prejudices, as
illiberal as they are alien to true philanthropy, obstacles are
daily arising in your Majesty's United Kingdoms to the
prosecution of anatomy. It is equally impossible not to
believe, what ample observations demonstrate, that the mag-
nitude to which they have already attained is, in its infalli-
ble and invincible operation, signally and seriously injurious
to your Majesty's subjects, both in the public service and in
all the ranks of private society. Many more of these than
unsuspecting benevolence could have imagined are doomed,
it were easy to prove, to a premature grave by the conse-
quent deficiency in this requisite science on the part of
those to whom the care of life and health is committed.
And I will state most respectfully to your Majesty, in evi-
dence of this alarming truth, well known and universally
deplored as it is in the schools of medical learning, one
circumstance of political importance enough, independently
of humane considerations, to justify the freedom which I
thus assume.
" In France, in Germany, and in Denmark the prosecu-
tion of anatomy is protected by their respective govern-
ments, and in them every facility is afforded for its com-
208
BUXTON: IS EXPERIMENTAL MEDICINE JUSTIFIABLE?
[N. Y. Med. Jour.,
plete and satisfactory study. Hence, in great degree, it is
of late years such of the medical youth among your Majes-
ty's subjects as are enabled by their circumstances proceed
to these foreign kingdoms in search of information of the
most valuable kind, being compelled thereto by the dread
of entering on the practice of their profession while igno-
rant of some of its fundamental principles, and of having,
through the unavoidable fault of a merely British education,
to collect, by repeated failures in their treatment of the liv-
ing, that knowledge which they might have early and safely
and ably acquired from intimacy with the dead."
These plates comprise within their range anatomy, physi-
ology, and pathology, and what Lizars said of the study of
the cadaver may well be repeated to-day of the study of
physiological medicine upon the living organism. If ex-
periment be eliminated from our methods, what will result ?
Instead of well-ordered and carefully planned trials, elabo-
rated and calculated beforehand, and executed by hands
deft in practice and ready of resource, we should have
bungling and blind empiricism, a priori reasoning, and the
havoc wrought of unrecognized experiments made by un-
skilled operators — operators, indeed, who may be serenelv
unconscious of the fact that they are executing experiments
galore upon their patients. We will, however, return to
this later on.
My next position is as follows :
To learn medicine we must adopt one of the following
plans of study ; that which is the best for the greatest num-
ber is, I venture to assert, the most justifiable. We must
wait for inspiration and miracles ; we must wait for acci-
dents, such as when a bull gores a hole in some unhappy
person's abdomen and establishes a gastric fistula, as oc-
curred to Dr. Busch's patient, so enabling him to study the
action of certain bodies upon the gastric mucous membrane ;
or, to take another " accident," we must observe the death
agonies of some unhappy victim of rat-poison, and learn that
strvchuine produces tetanus ; or (for a third course is open)
we may prearrange certain conditions, and then observe the
results of various alterations of such conditions — alterations
likely prearranged and submitting themselves to our abso-
lute control ; we may, in fine, use experimental medicine.
May I here again select an illustration?
I would choose the somewhat hackneyed case of nitrite
of amyl. The drug was found to dilate capillaries, and
hence to bleed the body into itself. The peculiar agony of
angina pectoris being accompanied with harrowing spasm
of the arterioles, was it not justifiable to employ nitrite of
amvl for the relief of angina pectoris ? I submit it was.
Now, of these three methods — which I will for brevity's
sake call the (1) method by supernatural interference, (2)
the method of accidents, (3) the experimental method —
which is the best ? Let us seek an answer in the experience
of the past and the practice of the present.
The supernatural method is distinctly a prehistoric mode
of going to work, but one that a certain prehistoric sect
still extant in our midst confidently practice and preach.
Most thinking men accept the wholesome tenet that the
Almighty helps him who helps himself. Sir William Ham-
ilton it was who adopted as his favorite aphorism,
" In the universe there is nothing great but Man ;
In Man there is nothing great but Mind."
Hence may we, I think, fairly reason that man being
endowed with a mind, points out that that mind should, in
all humility, work out the ends of science and expect not
inspiration and supernatural interposition in matters medi-
cal, although it may deeply and fervently be thankful if such
unlooked-for aid comes.
There was a flourishing school of medicine in Egypt,
over which presided a large sprinkling of demigods, and
even the Egyptian Apollo graced the faculty with his com-
pany. The priests, male and female, were herbalists, but
mainly relied upon superhuman aid. Herodotus said of
Egypt : " Every place is full of doctors." Herodotus, had.
he lived a few centuries later, might, I think, have made the
same remark of England. The institution of the school
of Alexandria was subversive of the superhuman aids to
medicine in Egypt. The accidents methods then came into
vogue. All was vague and uncertain, for the method of ex-
periment was as yet practically untried. I desire to avoid
wearisome narrative ; but it is worth your while, I think, to
spare time and thought concerning the growth of medicine.
It has convinced me of the justice of the cause I am de-
fending, and I believe it will convince you also. We all
know that the Jews were accomplished in many branches
of physic. They, like many who flourish among us, be-
lieved in hygiene, and were often content with a happy
diagnosis, leaving therapeutic details to take care of them-
selves. I have often heard, and not many miles from this
bnilding, the strange formula uttered : " Oh, give him a
placebo ; anything will do ; and keep him under observa-
tion ! " So, in my fancy, I can see the stately Levite, arro-
gant in his knowledge, diagnosticating " the emerods," " the
botch of Egypt," " a withered hand," or " epilepsy," and
then dismissing the " botch " patient with directions for a
fig plaster. History repeats itself. Before I leave Egypt
and Jewish physic lore I must say, in a parenthesis, thatr
in the first-named country, specialists were rife as now ; even
limbs and portions of limbs had their individual physicians !
How long before a Rameses sits upon the throne of the
Guelphs \
India, that profound enigma of buried civilization, knew
medicine as she knew the most perfect system of philosophy,
while Europe was in the most outermost of outer darkness.
But even India seems to have leant solely on inspiration and
accident for her medicine lore, and so she, too, never made
any sensible progress beyond incantation and herbalism.
China was as inexact. Her physiologists thought that
the human body was composed of water, fire, wood, metal,
and earth. Even now I have heard it remarked that a com-
mon belief obtains that some portions of some human bodies
owe their density to wood.
In Greece, medicine in the hands of Hippocrates is com-
monly held to have commenced its existence as a science.
To his efforts in part we owe the first step toward the eman-
cipation of medicine from the espionage of metaphysics and
religion. Hippocrates marks a most important epoch, and
his mistakes have importance not easily overestimated in
our discussion to-night. He used purgatives ; he talked of
AuguBt 22, 1885.] BUXTON: IS EXPERIMENTAL MEDICINE JUSTIFIABLE?
209
crises aDd the vis medicatrix natures ; indeed, the practice
was much the same as that of a far more recent medical
luminary. But remember, Hippocrates only experimented
upon his patients. This he did freely, and cured many.
He has, however, as far as a somewhat hasty search has
assured me, omitted to put upon record his rate of mor-
tality.
. Confessedly a successful practitioner, he failed to lead
the oncoming generations in the right way ; he taught his
humoral theory because his hands knew not the methods of
research and his mind was warped by incomplete observa-
tions; therefore Hippocrates hindered the progress of sci-
entific medicine for centuries. I have lingered here to show
that, for lack of scientific methods of research, a transcen-
dent genius went utterly astray. More than two thousand
years have sped since Cos begat her philosopher, and are
we endowed with more colossal brains than his ? can we
afford to throw away methods of which an Hippocrates
stood so sorely in need ? As the natural upshot of Hippo-
crates's transgression of his own canon — that no theory
should be accepted unless based upon the most [reliable of
observations — his disciples for generations accepted his con-
clusions with a faith worthy of a better occasion. For
centuries to come medicine was not ; herbalism rose rampant,
while slowly but surely was growing the foundation of a
scientific basis for medicine.
Anatomy was prosecuted with more or less exactness.
However, the main object of the physicians of those days
was to show how futile was the teaching of their brethren,
how ridiculous their practice. How different from the
faculty of to-day !
"Blest, thrice blest, the Roman
Who sees Rome's brightest day."
And, as far as medicine is concerned, Celsus was blessed
thrice, for it can not be said to have been extant until he
undertook its exposition. All, however, who have read
Celsus, although impressed by that great man's acumen and
remarkable power as a clinical observer, will not fail to find
in his writings a great want. Celsus knew naught of physi-
ology ; his wildest dreams never carried him beyond the
method of experimenting upon his patients. With Celsus
may be said to close one epoch, and with Galen to com-
mence another. I have already traced the onward progress
of physiology and anatomy through the very dark times of
the mediaeval ages ; it yet remains to learn whether medi-
cine, an older science, had advanced beyond these. Clearly
if medicine be a science which can be studied independently
of experiment, it should have advanced as facts were ob-
served and classified. But medicine not only made no
advance ; it even retrograded. Men were for the most part
more anxious to kill one another than to cure. Among the
Arabs the lore — for we can not give it a more dignified epi-
thet— was cherished.
I am coming now to Saxon medicine, a science some-
what behind what we would have it, but not one whit less
fantastic than the practice of him who refuses to avail him-
self of scientific methods of research. I will offer a few
excerpta from a quaint old book called " Leechdoms, Wort-
cunning, and Starcraft of Early England." For fever it is
recommended that a long (? canine) tooth of a black dog
be applied ; or, failing this, recourse was to be had to a live
wasp, which insect it was requisite to tie to the fever-stricken
patient's person. Among haemostatics was the following
incantation : " Stupid on a mountain went, stupid, stupid
was." Again, colic, we are told, yielded at once to the
thrilling words uttered in a low tone : " Stolpus tumbled
out of heaven." I do not know who Stolpus was, and, hav-
ing never tried the remedy, I can not vouch for its success.
It would be tedious to wade through more stuff of this sort ;
we may understand in what the practice of physic consisted
in those days, and we can see that in it is another example
of how medicine fares when dissevered from experimental
research.
Strange companions was poor Dame Medicine to have
before she attained her majority — an epoch I place at the
time when men wittingly commenced to introduce the sci-
entific spirit of experiment and research into her service.
In the seventeenth century medicine was a puny child,
supported and overruled by astrology. The science was
simple in theory. Herbs were used largely, but only by
him who knew the stars in their courses, and had, by toil-
some watching and coquetting with the black art, learnt
what times and seasons were opportune for each simple. I
give the following as an example :
It is " good to purge with electuaries the moon in Can-
cer, with pills the moon in Pisces, with potions the moon in
Virgo," etc.*
The book from which I quote was published only one
year before John Evelyn wrote in his " Diary " : " 16th July.
There died of the plague in London this week 1,100, and in
the week following above 2,000."
But light was breaking. The alchemists, whose writ-
ings are so fascinating from their plausible plans of perform-
ing impossibility, were breaking the ground for chemistry.
In 1774 came Priestley's discovery of oxygen, and from that
date we may trace the steady, if slow, progress of medical
chemistry. From hence the test-tube and the crucible were
called into requisition as exponents of the probable action
of drugs in the human body. But even such learned ped-
ants as Elias Ashmole (1681) were credulous, for I find him
curing his ague as follows: " April 11th. I took early in
the morning a good dose of elixir, and hung three spiders
about my neck, and they drove my ague away. Deo gra-
tias ! "
Harvey, as I have said, by his experiments actually
broke up the systems of previous medical thought, all more
or less erroneous, because based upon a priori grounds.
The inventors of these systems were innocent of experi-
mental methods of research, and hence, when Harvey dared
to fly in the face of their pet theories, they declaimed him
as infidel and madman. It was as in the story of Galileo.
The earth did move and the blood did circulate. Malpighi,
looking down the tube of his microscope, a poor enough
affair but inexpressibly precious to him, saw little discs roll-
ing and tumbling along. "Eureka ! " he cried ; the glorious
theory was visible to the eye, and seeing was believing.
* " The Husbandman's Practice or Prognostications Forever," 1664.
210
BUXTON: IS EXPERIMENTAL MEDICINE JUSTIFIABLE?
[N. Y. Med. Jock.,
Then the escapement gave way ; mad, reckless experiment
followed. Transfusion was practiced to an absurd extent.
Stories are numberless of criminals resuscitated and the
dead speaking. Even after such an impetus as Harvey's
grand^work gave, medicine made little progress. An age of
unreason as bad as that of the astrologers followed upon
the Paracelsian and chemical epochs. Newton's vast genius
caused all the lesser lights to gravitate toward him, and led
them to regard all the universe and its workings through
mathematical spectacles. Those who, by a fine flight of
fancy, deemed themselves physiologists, reduced that science
to one of pure numbers. Each organ was duly calculated
up, and its functions converted into logarithms. The
heart was said to execute its movements by dint of a force
of 180,000 pounds — that is, with the force of a small loco-
motive engine.
At this time the experimental method was being pushed
by men whose names still linger in our midst and impart
some element of historic interest to our hand-manuals,
which, little thanks to the crude hurry of this generation,
are usually written in as cut-and-dried and uninteresting a
way as ever quill-driver could execute. Now flourished
Lower, Malpighi, Bartholin and Steno, Swammerdam, John
Mayhew, Raymond Vieussens, John George Wirsung, and
Thomas Wharton, with Thomas Willis and Francis Sylvius.
These names should be coupled with Glisson's, Schemer's
and many others.
Sydenham, called England's Hippocrates, seems to have
done little experimental work save in the domain of thera-
peutics. His clinical descriptions will, if you ever care to
shake off the lethargy which induces so many of us to for-
get that we belong to an historical profession and should
know its history, reveal how accurately he observed and
how truthfully he delineated. Time, however, presses, and
the story lingers mid many shallow places — shallows of
thoughts and depths of ignorance.
The theory of Stahl need not detain us ; he taught that
the bodily necessities of the organism were presided over by
the soul. Hence he advised an expectant treatment (this was
the origin of the term), and sought to provoke the soul into
reacting remediably upon the body. This, of course, is prac-
tically an excrescence from the supernatural system. Stahl,
as one would expect, opposed the use of opium and cincho-
na bark, and pushed tartar emetic and the cupping dish.
Cullen it was who, collaborating the systems of Boer-
haave and Hoffmann, reduced physiological phenomena to
varying motions. The derangement in these internal move-
ments normal to an organ constituted disease.
Cullen was confronted by Dr. John Brown, one of the
ablest exponents of a hopelessly ridiculous system of thera-
peutics that ever retarded the progress of medicine. To
his philosophy, disease was dynamic or sthenic and asthen-
ic. His diagnosis, necessarily as often faulty as accu-
rate, was followed by bleeding and purging to the nth, or
stimulants pushed to a barbarous extreme. Dr. Erasmus
Darwin next comes to point the moral of the preceding
narratives. Like the humoral theory of Hippocrates,
Stahl's, Hoffmann's, and Brown's each rushed headlong into
a perfect quagmire of folly and illogical hypothesis, and all
this arose from the fact that these men formulated theories,
as ladies make patchwork quilts, from fragments left by
others. Darwin, in spite of his bombast and inconsistency,
was enabled to set these men right, because he, going
to the fountain-head of knowledge, direct experience,
showed by his own experiments that many of the premises
upon which his predecessors based their theories were un-
tenable. •
William and John Hunter are worthy names to mark an
epoch, and I need no evidence more emphatic than theirs
in support of the proposition which stands at the head of
my paper. With John Hunter there lived in the ties of
the closest friendship one called Dr. Edward Jenner. The
two Hunters and Jenner did more toward establishing
the science of medicine than perhaps any triumvirate of
contemporaries before or since. John Hunter tells us in very
plain English that " my brother William " and I did experi-
ments upon living animals. William Hunter's work upon
absorption, in itself and through the subsequent research it
excited, has produced results of the last importance to prac-
tical physicians. John Hunter's name is indissolubly united
with the experimental method ; nor can we esteem highly
enough his colossal advances in comparative anatomy and
physiology. One of his biographers records of him that he
esteemed surgical as second to medical aid, "for," he said,
" if we have to mutilate a body, which we do when we
assume the knife, we fail in the primary object of our treat-
ment to effect a cure."
Of Jenner and the introduction of vaccination what
shall I say ? To my mind, Jenner, the experimenter, stands
out in glorious relief against the dark background formed
by his detractors. Some will say that vaccination is not an
unmixed blessing. Let us be open to conviction ; but we
should also remember that there are persons who conceive
the earth is a flat surface ; are such theorists to be treated
as reliable ?
Vaccination, involving as it did the whole theory of at-
tenuation of morbific virus, as well as the practice of pro-
tection by the use of such attenuated virus, has opened a
new research field, and one promising a most ample harvest.
It is not too much to say that to Jenner we owe countless
precious lives and happy homes ; yet this man was an ex-
perimenter ! Was he not justified ?
And now we have passed the most barren part of our
history and come upon times when men began to recognize
the necessity of treating medicine from the standpoint of
science. Floods of light began to be flung upon every page
of medical lore. The pathologist no longer spoke in terms
of a humoral theory ; ceasing to waste time over spirits per-
vading nerves, he adopted the plain and only safe method
of seeing first and believing afterward. Physicians passed
beyond herbalism and began to inquire how disease could
be explained and how treated upon rational principles. It
is not necessary, nor does time permit me, to carry my narra-
tive further. All who are here will readily in his own mind
fill in the hiatus. I have attempted to trace the series of
circumstances which led up to the introduction of the scien-
tific method in medicine ; that task accomplished, it will be
not difficult for you to pursue the subject and determine
August 22, 1885.]
BUXTON: IS EXPERIMENTAL MEDICINE JUSTIFIABLE?
211
how far each subsequent observer increased knowledge by
experiment and fortified clinical experience by an appeal to
direct fact.
We have — I hope not too laboriously — waded through
what has been done in the past by way of promoting the
advance of medicine. We have seen that that advance has
been made by the experimental method, and it has been
open to us to appreciate a further fact — that when medicine
has touched upon theoretical ground, unsupported by ex-
periment, she has only too often been obliged to retrace
her steps. The present aspect of the question has yet to
be confronted. In our every-day practice we shall meet
with diseases which are grouped according to our nosologi-
cal systems, but which will, more or less, resist our book
methods of treatment.
What are we to do ?
Again, we shall daily learn the force of a great truth —
that what our books teach us is inapplicable, is even false,
when applied by the rigid law of rule of thumb.
What are we to do?
Those of us who care for more than hand-to-mouth
work, and certainly those who care for successful treatment,
will awaken then to know that all their true learning of
medicine has yet to be accomplished, and has to be gained
at the bedside of the patient. Nature will give them the
problem ready for solution ; the answer they will arrive at
by themselves.
We shall, each of us, adopt one of two methods: We
shall follow, as nearly as we can, in the steps of our teach-
ers, and test, as far as we can, the truth of their statements
concerning diagnosis and treatment upon our patients ; or
we shall soar farther and try fresh departures in diagnosis
and treatment. The first method — the more usual one — is
still an experimental one.
It will appear to you as clearly as the sun at noon-day
that every time drugs are given, baths or what not applied,
an experiment is performed, and the success of your treat-
ment will depend upon the accuracy of your diagnosis and
the proportioning of your doses. Take the B. P. If any one
blindly follows its doses, do you think he would cure any
one ? The B. P. dose-list is a literary cow-catcher, insti-
tuted with the hope of preventing toxic doses being blindly
given. No ; you must give not only not an excessive dose,
but equally important is it not to give an inactive dose. A
friend of mine, when salicylates were not so commonly
given as now, complained to me that his experience of
willow bark was most unsatisfactory. He had seen the
salicylism following full doses, and hence had given gr. iij
three times a day. Acute rheumatism proved too much for
him.
What are we to do ? Our B. P. gone, we can only hang
upon the lips of our teachers and hunt up stray prescrip-
tions amid our manuals ; failing these, we must search for
tips in current treatises. No, I venture to say, none of
these will suffice ; you must learn how to experiment and
push your remedies ; you must do that which, until it is ex-
plained, seems so unhallowed and so cowardly ; you must
make your patient the subject of an experiment.
Now, see, there is no help for it ; you will either experi-
ment when you don't know it (and woe be to your patient),
or, armed cap-a-pie with therapeutical lore, you will give
him the best chance of benefiting from your skill. Now
we go a step farther. All modes of treatment are based
upon some general basis or ground for action, and it hap-
pens often enough that fresh departures in these modes of
treatment seem demanded. Take an example. A large
experience of fever showed that if the skin were cooled and
its discharges removed, the well-being of the patient was in-
sured. Cold water laved over head and arms gave relief; it
was determined to try the cold bath. If you have seen — as
some of you doubtless have — cases of hyperpyrexia, you
will bear me out when I say, to me no case is so terrible, no
patient wrings more one's heart-strings, than does the sub-
ject of that frightful condition. Is the cold-bath experi-
ment justifiable ? I believe yes. I have seen patients
stricken with typhoid fever whose temperature, running up,
has demanded heroic treatment. I have seen in some cases
these poor people scream with fear and horror as they were
lowered in the bath, and yet when they have been replaced
in bed they have sunk into refreshing sleep and have ral-
lied. That experiment was, I think, justifiable. If in the
first cases of hyperpyrexia, the first cases of typhoid fever,
the patients had died in spite of the bath, what would have
been said ?
Again, take drugs. It is a fact that many plants alike
in botanical characters show a kindred action upon disease.
To determine whether such is so in any case we have two
plans to administer the drugs — to animals or to patients.
The former method is highly deceptive, and can only be
employed tentatively and as a preliminary to the adminis-
tration to human beings. We are here discussing only the
broad principle ; there are many by-issues. The danger of
the drug, the severity of the symptoms, would, of course,
enter largely into the question of justifiability. In the
cases above mentioned we have argued upon the question,
Is it justifiable to experiment upon patients for their own
good? and I have answered in the affirmative. What shall
be said concerning the further question, Is it justifiable to
experiment upon a man for the good of the community?
Here I must adopt another answer. I should say that, at
least as far as therapeutic research is concerned, the broad
principle upon which we must work involves a negative
answer. That there are exceptions I should be ready to
admit ; that researches which could involve neither risk nor
ultimate inconvenience might justifiably be made I am pre-
pared to believe. These cases I should expect would rest each
upon its own merits. But that experimental therapeutics is
justifiable when contingent dangers and inconveniences are
fully put before the persons to be the willing subject of
such experiments, I hold needs no championship of mine.
Enough, I think, has already been said to show more than
amply that the only true progress on the therapeutic side
of medicine will occur as the outcome of such experiment.
Yet another side of this question has to be considered
— one which ranks high in importance. To the few it
occurs to learn medicine from observations of its results.
In the dead-house, with scalpel, with microscope, with chemi-
cal test-tube, the scientist elaborates there a pathogenesis
212
MACKENZIE: HISTOLOGY OF ACUTE AND CHRONIC CORYZA. [N. Y. Med. Jouk.,
which, with logical mind cultured in clinical records, leads
him to a rational theory of disease. Now, to complete the
chain of his reason, he needs to be able, by employing known
morbific influences, to induce in his patient the pathological
lesions he has seen and dissected. I can hardly take better
instances than those of Ferrier's, Schafer's, and Horsman's
experimental work upon brain areas ; or, again, the last-
named observer's splendid results in myxcedema.
The whole range of miasmatic and infective diseases,
tuberculosis, splenic fever, chicken cholera, rabies, and per-
haps we may add cholera, all have been elucidated, arranged,
and brought within the scope of things understandable by
experimental methods. It can not be said that these dis-
eases have as yet been rendered amenable to treatment, but
much has been done, and Pasteur has given earnest that in
the future much may be done to obviate their occurrence.
And, gentlemen, prevention is better than cure.
A CONTRIBUTION TO THE PATHOLOGI-
CAL HISTOLOGY OF ACUTE AND
CHEONIC CORYZA*
By JOHN N. MACKENZIE, M. D.,
BALTIMORE.
In the " Philadelphia Medical News " of October 4,
1884,f I gave an account of the changes found in the differ-
ent stages of intra-nasal inflammation, which was based
upon the anatomical study of a large number of
neoplasms removed from the nasal passages by
means of the cold-wire snare. The object of the
present communication is to call attention to some
additional points in the pathological anatomy of
that affection, which I trust may prove of gen-
eral interest, both from a clinical and histological
point of view.
The first specimen that I submit to your ex-
amination (Fig. 1) represents the microscopical
appearances of a section through the inferior tur-
binated body of a man dead of Bright's disease,
the result of long-standing mitral regurgitation
and insufficiency.;];
Among the ordinary visceral changes usually
found in such cases there were traces of old infarc-
tions in both kidneys and spleen. The nasal pas-
sages presented the appearances commonly ob-
served in the condition known as coryza, and in
the permanent puffy condition found in more
chronic inflammation, the most noticeable being
intense engorgement of the cavernous tissue, es-
pecially well marked over the lower half of the
middle and posterior portion of the inferior turbinated
body. Upon cutting into the engorged bodies with a
* Read before the American Laryngological Association, June 26,
1885.
f "Some Notes on the Pathology of Intra-nasal Inflammation."
% I am indebted to Dr. W. T. Councilman, Associate in Pathology
in the Johns Hopkins University, both for the beautiful section and
notes of the post-mortem examination upon which these remarks are
based, and for the accurate drawings which illustrate the text.
scalpel, the blood, which flowed freely, could be squeezed
from them as water from a sponge. The mucous mem-
brane of the maxillary sinuses was not in the slightest
degree tumefied, and presented simply a more or less cy-
anotic appearance.
Under the microscope, the condition which at once
attracts the eye is the enormous dilatation of the erectile
spaces and the extreme tenuity of the intercellular walls.
Here and there rupture of the latter has occurred from the
enormous blood pressure, and two or more spaces in this
way communicate. Along the inner walls of the dilated
spaces are seen congregations of lymphoid corpuscles, and
in some of them collections of fibrinous exudation.
The mucous membrane proper presents no noticeable
pathological change. The epithelial layer is intact. At
some places it seems slightly thicker than at others, but,
beyond a moderate amount of cellular infiltration of the tis-
sues beneath the basement membrane, there is nothing in
the mucous layers to call for special remark.
Jutting out from and attached to the wall of the central
sinus (in the diagram) is a well-formed parietal thrombus,
to which I would like to call particular attention.
I bring this case before you for discussion as one of pe-
culiar interest, for it is instructive in many ways. So far
as I am aware, the histological appearances in acute coryza
have never been investigated. In this specimen we have
the probable microscopical picture of that disease. Here,
X
#
w
a.
Pig. 1.
too, is illustrated the minute anatomy of the puffy condition
or state of permanent dilatation of the erectile spaces which
characterizes the second period of the simple inflammatory
stage before hypertrophic changes have developed, and to
which I have called attention elsewhere.*
* See article referred to, and also a paper in the " Medical News "
of April 4, 1885, entitled, "Notes on the Classification, Diagnosis, and
Treatment of the Stages of Chronic Nasal Inflammation."
August 22, 1885.] MACKENZIE: HISTOLOGY OF ACUTE AND CHRONIC CORYZA.
213
Of great interest, too, is the formation of the parietal
thrombus, as illustrative of a mode of obliteration of the
erectile spaces heretofore unrecognized.
In connection with the negative post-mortem appear-
ances found in the maxillary sinus I would like to offer
some suggestions on the relation of inflammatory affections
of that cavity to intra-nasal processes.
While I am convinced that the chronicity of certain
forms of nasal disease, the persistency of a fair propor-
tion of neuralgic (and other reflex neuroses) affections
of the head and face, are traceable to latent or unsus-
pected chronic antral inflammation, while it is doubt-
less true that affections of the maxillary sinus often run
their course unrecognized during life, the secondary im-
plication of that cavity in acute and chronic inflammatory
processes originating in the nasal passages is, comparatively
speaking, rare.
Inflammation of the maxillary sinus may result from
congenital or acquired defect of the naso-antral aperture, or
from its closure by the swollen and hypertrophied nasal
tissue, polypi, crusts, etc., conditions which may favor the
retention and decomposition of the antral secretion. In-
flammation from this cause, however, occurs less frequently
than is universally taught by inference from purely theo-
retical considerations. I base this assertion not only on
clinical observation, but also on the results of post-mortem
investigation. Those of you who choose to investigate the
anatomical aspect of this question will be amazed
to find how infrequently the mucous covering of the
sinus participates in the inflammatory condition of
the nasal fossae. It is the rule to find the most
marked hypertrophy of the nasal tissues, and even
complete atrophy, associated with a normal condition
of the sinus. What is the explanation of this fact?
On the nasal aspect of the naso-antral opening
is a duplicative of the erectile tissue of the turbi-
nated bodies, which in all probability serves the
useful purpose of excluding from the cavity of the t- — —
sinus, by means of the anatomical barrier involved
in its erection, various irritants derived from the
external world and nasal passages. This tissue
ceases abruptly at the antral aperture. On the
other side of the opening lies the peculiar loose,
vascular membrane of the sinus. In the majority
of cases this zone of erectile tissue constitutes the
extreme anatomical limit of the nasal inflammation.
The thin, loose, serous-looking membrane of the
sinus differs essentially from the nasal mucous mem-
brane, and especially that portion which surrounds
the entrance into the maxillary sinus, and the abrupt
transition of the one tissue into the other would therefore
militate, on theoretical grounds, against extension of the
inflammatory process into the antrum. In other words, I
bel ieve that the so-called extension of inflammatory action
from the nasal passages to the antrum — the secondary in-
flammatory implication of that cavity — is of comparatively
infrequent occurrence ; and that, when inflammation of the
sinus from extension is assumed, the condition will be found,
on postrinortem examination, to be one of simple conges-
tion, with possibly some accumulation and retention of the
antral secretion from mechanical causes. Even if the
amount of secretion be temporarily increased, the great
power of absorption possessed by the membrane of the
sinus will usually suffice to make it a matter of secondary
importance.
I am inclined to believe that too much stress is laid
upon the decomposition of antral secretion as a factor in
the production of inflammation. Take, for example, a sim-
ple coryza. With the general erection of the turbinated
tissues the orifice of the antrum is completely closed, con-
gestion follows, with possibly an increased secretion of the
antral fluid. Whether this secretion, thus hermetically
sealed, so to speak, in the antrum undergoes decomposition
before the patency of the opening is restored and the air
gains admittance, is questionable; but, on the other hand,
that decomposition does occur is beyond dispute, for, when
the swelling from the acute rhinitis subsides, the aperture be-
comes free and, in some instances, the foetid antral secretion
is discharged into the nasal passages, a fact which accounts
for the peculiar fcetor of the expired air from the nostrils
which is sometimes observed at the close of a severe
coryza.
In the second specimen (Fig. 2) are shown the micro-
scopical appearances in the hypertrophic stage of chronic
nasal inflammation before complete obliteration of the erec-
tile spaces has taken place. Contrast the condition here
Fig. 2.
with that found in the first specimen and in the acute and
earlier stage of chronic rhinitis. Observe closely the little
buds or bulbous processes which jut out from the walls of
the cavernous sinvses, and which are made up of out-
growths from the newly formed intercellular connective
tissue. In my anatomical study of this stage I overlooked
these little buds, and my attention was subsequently called
to them by my friend, Dr. Councilman, who had taken one
of my sections for examination.
214
BOOK NOTICES.
[N. Y. Mku. Joob.,
Projecting inward, they form bulbous processes or
septa of varying thickness, which sometimes interlace,
sometimes form bands which connect one portion of the
sinus-wall with another, thus constituting another factor in
the division and obliteration of the cavernous spaces.
Care should be taken not to confound them with the re-
mains of a thinned and ruptured intercellular wall ; in the
latter case a similar projection will usually be found at a
point diametrically opposite to that occupied by the pro-
jecting band.
We have, then, four modes of obliteration of the erectile
spaces in nasal inflammation :
1. By the contraction of the newly formed intercellular
fibrous bands.
2. By obliteration of their lumen by masses of round
cells which resemble the white corpuscular elements of the
blood. (See first article in the " Medical News.")
3. By the formation of thrombi in certain cases.
4. By the process of septa formation.
jtook flotices.
The Bar: its Anatomy, Physiology, and Diseases. A Practical
Treatise for the Use of Medical Students and Practitioners.
By Charles H. Burnett, A. M., M. D., Professor of Otology
in the Philadelphia Polyclinic and College for Graduates in
Medicine, etc. With One Hundred and Seven Illustrations.
Second Edition, Revised and Rewritten. Philadelphia :
Henry C. Lea's Son & Co., 1884.
The first edition of Dr. Burnett's work, published seven
years ago, was in every way worthy of the kind reception ac-
corded it, and it has been a matter of surprise to many workers
in the field of otology that so long a period has elapsed before
the appearance of the second edition. The science of otology
has in this period made very rapid advances, many of them of
an exceptionally practical character. These have made neces-
sary many alterations in the first edition, and some of the chap-
ters have been practically entirely rewritten. The result ap-
pears in a handsome volume of nearly six hundred pages,
printed in large, clear type on good paper, and with numerous
illustrations in the text. Large additions have been made to
the text, especially in the articles on Abnormities of the
Auricle, on the Treatment of Chronic Otorrhoea, and the sub-
ject of Aural Polypi. The arrangement of the chapters is much
the same as in the first edition, about two hundred pages
being taken up with a description of the anatomy and physi-
ology of the ear, and a discussion of the theory of sound and
hearing, and the method of the examination of patients. There
is a very satisfactory presentation *of the subject of otomycosis
and its treatment by the insufflation of germicide powders.
There are some interesting pages upon Organic Disturbances in
certain Diseases of the Middle Ear. The chapters on the Treat-
ment of Chronic Purulent Inflammation of the Middle Ear and
on the Course and Consequences of Chronic Purulent Inflam-
mation of the Middle Ear are excellent, and throughout the en-
tire work may be noted the painstaking care of the author in
bringing the second edition abreast with the advances made in
otological science up to the present time. From a careful peru-
sal of the work in its new dress, it may be seen that the second
edition is as worthy of a welcome reception as the first one was.
BOOKS AND PAMPHLETS RECEIVED.
A New England Conscience. By Belle C. Greene. New
York: G. P. Putnam's Sons, 1885. Pp. 196.
Report on the Mortality and Vital Statistics of the United
States as returned at the Tenth Census (June 1, 1880). By John
S. Billings, .burgeon, United States Army. Part I. Washing-
ton: Government Printing Office, 1885. 4to, pp. lxiii-767.
Comparative Anatomy and Physiology. By F. Jeffrey Bell,
M. A., Professor of Comparative Anatomy at King's College.
Illustrated with 229 Engravings. Philadelphia: Lea Brothers
& Co., 1885. Pp. xii-555.
Diseases of the Tongue. By Henry T. Butlin, F. R. C. S.,
Assistant Surgeon and Demonstrator of Practical Surgery and
Diseases of the Larynx, St. Bartholomew's Hospital, etc. Illus-
trated with Chromo-lithographs and Engravings. Philadelphia:
Lea Brothers & Co., 1885. Pp. viji-451.
Elements of Modern Medicine; including Principles of Pa-
thology and Therapeutics, with many useful Memoranda and
Valuable Tables for Reference, etc. Designed for the Use of Stu-
dents and Practitioners of Medicine. By R. French Stone, M. D.,
Professor of Materia Medica, etc., in the Central College of Phy-
sicians and Surgeons, Indianapolis, etc. New York: D.Apple-
ton & Co., 1885. Pp. xiv-368.
Second Report of the State Board of Health of the State of
Tennessee, October, 1880-December, 1884. Nashville: Albert
B. Tavel, Printer to the State, 1885. Pp. xv-600.
Lehrbuch der Physiologie fur akademische Vorlesungen und
Selbstudium. Begriindet von Rud. Wagner, fortgefuhrt von
Otto Funke, neu herausgegeben von Dr. A. Gruenhagen, Pro-
fessor der medizin. Physik an der Universitat zu Konigsberg
i/Pr. Siebente, neu bearbeitete Auflage. Mit etwa Zweihundert-
undlunfzig in den Text eingedruckten Holzschnitten. Sechste
Lieferung. Hamburg u. Leipzig: Leopold Voss, 1885. Pp.
113 to 272, inclusive.
Medical Legislation : the Annual Address delivered before
the Association of American Medical Editors. By Henry O.
Marcy, M. D., etc. [Reprinted from the " Journal of the Ameri-
can Medical Association."]
Notes from the Physiological Laboratory of the University
of Pennsylvania. Edited by N. A. Randolph, M. D., etc., and
Samuel G. Dixon, etc. Philadelphia: J. B. Lippincott Co.,
1885. Pp. 88.
Illinois State Board of Health. State Sanitary Survey. Sani-
tary Schedule, etc. Pp. 44.
The Scientific Transactions of the Royal Dublin Society,
July and November, 1884, and February, 1885.
The Scientific Proceedings of the Royal Dublin Society,
July, 1884, and January, 1885.
Experiments upon the Heart of the Dog, with reference to
the Maximum Volume of Blood sent out by the Left Ventricle
in a Single Beat, and the Influence of Variations in Venous
Pressure, Arterial Pressure, and Pulse-rate upon the Work done
by the Heart. By W. H. Howell, A. B., Fellow of the Johns
Hopkins University, Baltimore, and F. Donaldson, Jr., A. B.,
M. D., Scholar in Biology in the same. [Reprinted from the
" Philosophical Transactions of the Royal Society."]
Hints on Digestion. A Brief Resume of the Latest Physio-
logical Investigations. From various English, American, French,
and German Physiological Writings. New York: The New
York Pharmacal Association.
A Case of Primary Epithelioma of the Tonsil. By F. Don-
aldson, Jr., B. A., M. D., etc., Baltimore. [Reprinted from the
" Medical Record."]
Association of the Alumni of the Albany Medical College.
Proceedings of the Twelfth Annual Meeting.
August 22, 1885.]
LEADING ARTICLES.
215
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by
D. Appleton & Co.
Edited by
Frank P. Poster, M. D.
NEW YORK, SATURDAY, AUGUST 22, 1885.
THE BRITISH AND THE AMERICAN MEDICAL ASSOCIA-
TIONS.
Between the American Medical Association and its really
great prototype, the British Medical Association, about as much
resemblance may be traced as between "Punch's" little India-
rubber effigy of the First Napoleon and the statue of Julius
Caasar, in the cartoon which represented Louis Napoleon vigor-
ously inflating the former and remarking to the statue of the
great Roman : " Aha, monsieur, I shall soon make him so big
as you ! " Faint as the likeness is, however, between the two
associations, and rapidly as even the most ambitious aspirations
of our American organization are being crushed out of it by
mismanagement, it may not be amiss to reflect upon some of
the difficulties which beset large bodies of men banded to-
gether, in spite of clever management. But, first, in order to
set forth more precisely one phase of the difference between
the British and the American associations, we will quote fr»m
certain comments by the "Medical Times and Gazette," of
London, on the affairs of the British Medical Association.
" The lamentable muddle into which the sister association in
the United States has thrown the medical profession in that
country," says our contemporary, "has come upon us as a
revelation, to make us grateful for the policy which has kept
our own association free, on the whole, from the machinations
of self-seeking wire-pullers, and has kept a sufficient place of
honor for the scientific leaders of the profession. Reading of
what has recently happened across the Atlantic, we ought to
be thankful that the powers of our own association have not
been abused, as they might have been, to the forcing upon us
of leaders whose only claim to leadership is skill in the lobby.
An association, again, which can tolerate homoeopaths upon its
roll contrasts very favorably, in respect of discretion and liberal
feeling, with one which, like the American association, ostra-
cizes regular practitioners simply for claiming the individual
liberty of holding consultation with whom they please."
But the " Times and Gazette " confesses that it can not help
feeling that the success of the British association is "a little
hollow," and it proceeds to show the great degree to which the
prosperity of the association depends upon the excellence and
the acceptable character of its publication, the " British Medi-
cal Journal." The article then goes on, in a manner most
creditable to the journal in which it appears, to call attention
to the pre-eminent ability of the editor of the " British Medical
Journal." But the "Times and Gazette" hints that the very
mainspring of its present prosperity, its journal, may yet prove
a stumbling-block to the association. It fears what may hap-
pen with the journal in other hands, and states its conviction
that the association " can not be declared to be an assured suc-
cess until it has weathered, once or oftener, a change in the
editorship of its journal."
We have no doubt that any one familiar with the work of
editing a medical journal will appreciate the solicitude felt by
the "Times and Gazette," even in the case of any important
journal, and doubly in the case of one that, like the " British
Medical Journal," has to cater at the same time to the demands
of its readers at large and to the special interests of the associa-
tion of which it is the organ. If there is occasion for such a
feeling of insecurity with regard to a journal and an association
both so well established as those in question, how much greater
ground is there for guarding against the contingency of a
change of editorial management in the case of the "Journal of
the American Medical Association." That publication is still
in its infancy ; yet on more than one occasion efforts have been
made to take it out of the hands of its present editor — efforts
which we have always regarded as unwise, and against which
we have raised our voice from time to time. If a change in its
editorship would be perilous at any time, it would be tenfold
more dangerous at a time when the journal is still undeveloped,
and the association itself in a condition that has called down
upon it the indignation of hundreds who in the past have been
among its most efficient supporters, and who are now unable to
see any reasonable prospect of its soon resuming the honorable
position which it occupied a few years ago.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Health Department for the following
statement of cases and deaths reported during the two weeks
ending August 18, 1885 :
DISEASES.
Week ending Aug. 11.
Week ending Aug. 18.
Cases.
Deaths.
Cases.
Deaths.
14
4
23
6
8
2
25
4
Cerebro-spinal meningitis. . . .
2
1
1
1
16
2
31
3
20
14
30
16
1
0
0
0
Yellow Fever in New York.— It is reported that, on Wed-
nesday last, a sailor, recently arrived from Cuba, was found in
a hall-way, in the lower part of the city, suffering from yellow
fever.
Anthrax in Illinois. — A disease, said to be of the anthrax
variety, is prevailing among the cattle in the neighborhood of
Bloomington.
The Health of Chicago.— The " Condensed Statement of
Mortality" for July, published by the Health Department,
shows that there were 16 deaths from measles, 12 from scarlet
fever, 31 from diphtheria, 13 from croup, 14 from whooping-
cough, 2 from typhus, 79 from typhoid fever, 15 from cerebro-
spinal fever, 19 from malarial fever, 456 from dhirrhceal dis-
eases, and 54 from other zymotic diseases. In 1884 the popu-
lation, according to the School Census, was 630,000.
The Pension Board of New York City.— The Board of
Examining Surgeons for this city has been re-organized by order
216
MINOR PARAGRAPHS.
[N. Y. Mhd. Jock..
of the Commissioner of Pensions. The members of the late
board were Dr. S. S. Burt, Dr. A. B. Judson, and Dr. W. C. Mc-
Donald. The new board is composed of Dr. W. C. McFarland,
Dr. Ira Wilcox, and Dr. L. P. Walker. This action of the Com-
missioner is understood to be based on political grounds.
The University of Vienna. — The " Medical Times and
Gazette," of London, learns from its Vienna correspondent that
Prof. Bamberger has recently been elected Rector Magnificus
of the university. This disposition of the honor, the highest in
the gift of the university, is as much a compliment to the medi-
cal faculty as to the individual. The post is held for one aca-
demical year.
The American Dermatological Association will hold its
ninth annual meeting at Indian Harbor Hotel, Greenwich,
Conn., on Wednesday, Thursday, and Friday, August 26th, 27th,
and 28th.
The International Medical Congress.— It is understood
that the American Medical Association's new committee will
hold a meeting in New York on the third of September.
The Death of Dr. Francis Ashhurst, of Mount Holly, N.
J., took place on Monday, August 17th, in his forty-third year.
He was graduated from the University of Pennsylvania, De-
partment of Medicine, in 1867, and, in conjunction with his
mother, founded the Burlington County Hospital at Mount
Holly. He was a member of the Philadelphia County Medical
Society.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from August 8, 1885, to August 15, 1885:
Campbell, John, Colonel and Surgeon. Granted leave of ab-
sence for one month. S. 0. 184, A. G. O., August 13, 1885.
Ite6, Franois J., First Lieutenant and Assistant Surgeon (re-
cently appointed). Ordered for duty in the Department of
the Platte. S. O. 184, A. G. 0., August 13, 1885.
Azpell, Thomas F., Captain and Assistant Surgeon. Retired
from active service August 10, 1885. S. O. 181, A. G. O.,
August 10, 1885.
Chapin, A. R., First Lieutenant and Assistant Surgeon. Grant-
ed one month's leave, to take effect when service can be
spared by commanding general, Department of the Missouri,
with permission to apply for one month's extension. S. O.
179, A. G. 0., August 6, 1885.
Wales, Philip G., First Lieutenant and Assistant Surgeon
(Fort Cceur d'Alene, Idaho). Ordered for temporary duty at
Boise Barracks. Idaho. S. 0. 130, Department of the Colo-
rado.
Appointment.
Kendall, William P., to be Assistant Surgeon, United States
army, with the rank of first lieutenant, to date from August
12, 1885.
Marine-Hospital Service. — Official List of Change* of
Stations and Duties of Medical Officers of the United States
Marine-Hospital Service, for the two weeJcs ending August 15,
1885.
Bailhaohe, P. H., Surgeon. To proceed to Delaware Break-
water Quarantine as inspector. August 15, 1885.
Stoner, George W., Surgeon. Granted leave of absence for
thirty days. August 10, 1885.
Society Meetings for the Coming Week:
Monday, August 24th: Boston Society for Medical Improve-
ment.
Wednesday, August 26th : Auburn City, N. Y., Medioal Asso-
ciation; Berkshire District, Mass., Medical Society (Pitts-
field); American Dermatological Association (first day —
Greenwich, Conn.).
Thursday, August 27th: Cumberland County, Me., Medical
Society (Portland) ; American Dermatological Association
(second day).
Friday, August 28th : American Dermatological Association
(third day).
OBITUARY NOTES.
D. Colden Murray, whose death at the New York Hospital
on the 17th of this month has brought distress to a large circle
of friends, deserves more than a passing notice in our columns.
If such men as he were more numerous in the controlling
boards of our hospitals and educational institutions, the future
of medical education would cause us no uneasiness. Single-
minded, liberal, broad in his estimate of his fellow-men, dis-
criminating, just, there are few to replace him in the ranks
where many such are needed. He entered the hospital as a pa-
tient because of the advantages of the proximity of the surgeons.
His malady was a sarcoma of the bladder, and the operation
which was performed gave only temporary relief, which was
all that could be hoped.
He was born at the country seat of his father, Robert I.
Murray, at Coldenbam, N. Y., on October 10, 1821, and comes
from Revolutionary ancestry, being a great-grandson of Cad-
wallader Colden and John Murray, of Murray Hill, whose beau-
tiful wife kept the British officers at luncheon while Washing-
ton was crossing the river. He was also a grandnephew of the
grammarian, Lindley Murray. The foundations of an excellent
education were laid at Haverford College, to which he went at
the age of fourteen. He began his business life in the shipping
house of De Peyster & Whitmarsh, in this city, and was after-
ward connected with the firm of Hussey & Mackey, ship-brokers,
at No. 62 South Street. This firm was subsequently changed
to Hussey & Murray, and still later to Murray, Ferris & Co.
The latter firm operated a line of steamers to Savannah, which
was kDown as Murray's Line. The firm also had an interest in
a line to Cuba, and owned many sailing-vessels. In 1879 Mr.
Murray retired from the firm, and has done no business since,
but has devoted his time to charitable objects.
Besides being secretary of the Society of the New York
Hospital, succeeding his father, who served from 1824 until his
death in 1858, he was treasurer of the New York Dispensary
from 1856 to 1884, a director of the Sailors' Snug Harbor, a di-
rector of the United States Fire Insurance Company, and was
connected with other insurance companies. He was one of the
founders of the New York Club, and continued a member of it
until a short time ago. He was a member of the Union League
and St. Nicholas Clubs. For many years he was a warden of
St. Ann's Church, at which his funeral took place on Thursday
afternoon, when the Rev. Dr. Gallaudet conducted the services.
The burial was at Delhi, where live the family of his wife, who
survives him.
His interest and his strong protecting arm have done service
which should never be forgotten. To him the Training School
for Nurses at the New Y'ork Hospital owes its existence and
prosperity ; to him the Pathological Department of that insti-
tution is under the greatest obligations ; and his interest in the
welfare of the patients and doctors in the Chambers Street Hos-
pital, the Bloomingdale Asylum, and the New York Dispensary
has been as untiring as it has been intelligent.
Many of our readers whose success in life has doubtless been
in no small degree aided by a connection at some time with the
New York Hospital will feel his loss most keenly.
August 22, 1885.]
PROCEEDINGS OF SOCIETIES.
217
PHILADELPHIA CLINICAL SOCIETY.
Meeting of May 22, 1885.
The Vice-President, Dr. Amy S. Barton, in the Chair ;
Mary Willits, M. D., Reporting Secretary.
Removal of a Lymphoma from the Neck ; Recovery.—
Dr. Susan P. STAcicnousE reported the case of a woman forty
years of age. Sixteen years ago she first noticed a small tumor
just below the left ear; it caused no inconvenience except the
projection of the ear-ring. On seeking medical advice, she was
told that there was no danger attending the growth so long as
it remained undisturbed. It increased in size gradually, and
was attended with neither pain nor tenderness. The patient
entered the Woman's Hospital of Philadelphia, and was oper-
ated upon October 17, 1884, by Dr. W. W. Keen. At the time
of the operation the tumor extended from the ear to an inch
below the cricoid cartilage, and was two inches and a half in
width, its size affecting deglutition and respiration. The skin
was not involved, but the veins were enlarged, and two pulsat-
ing vessels could be felt to enter the tumor. The growth was
firm and inelastic, and movable to a certain extent.
After the patient was etherized, an incision four inches long
was made, care being taken to avoid the external jugular vein,
which crossed the growth. The haemorrhage, which was quite
profuse, was controlled by Ineinostatic forceps and ligatures, it
being necessary to ligate eighteen vessels. On account of the
vascular nature of the growth, and its loose connections with
surrounding structures, the adhesions were broken up with the
grooved director. The tumor was intimately connected with
the internal jugular vein for nearly three inches, and very care-
ful dissection was required in order to preserve the integrity of
that vessel. The wound was closed by wire sutures, after the
introduction of a drainage-tube and a bundle of horse-hairs.
The operation required one hour, and the patient became very
much exhausted, but reacted very quickly after a hypodermic
injection of brandy. The wound was dressed on the following
day on account of there being considerable oozing of blood ;
the tube was then removed, the horse-hairs being left. After
this the patient did very well ; the temperature never reached
100° F., the only difficulty being some trouble in deglutition for
three or four days. On the eighth day the dressings were re-
moved scarcely soiled; the wound was closed with the excep-
tion of one small point. The patient was discharged from the
hospital two weeks later.
Complete Retroversion of the Uterus from Distension of
the Bladder. — Dr. STACKnousE also reported a case of this af-
fection to which she was called July 22, 1884, it being said that
the patient was dying. She found a woman, thirty-five years of
age, with normal temperature; pulse 100, feeblo and irregular;
respirations gasping and rapid; face anxious and eyes injected.
She did not complain of pain, but had a constant desire to uri-
nate, and stated that she had passed urine repeatedly. Pressure
upon the abdomen caused a slight flow of urine. The abdomen
was greatly distended, the patient stating that the enlargement
had existed for ten days, and had come on suddenly and without
any previous illness. She did not think that she was pregnant.
On examining the abdomen, its enlargement was found to be
due to an oval, elastic tumor, extending from the symphysis
pubis to within two inches of the ensiform appendix. It was
regular in outline, and in no way resembled a pregnant uterus.
An examination per vaginam showed that the tumor had no
connection with the uterus, that organ being completely retro-
verted, the fundus being only a short distance from the vulval
orifice, and the cervix behind the symphysis pubis. The uterus
was somewhat enlarged and perfectly immovable. The patient
insisted that sha was not pregnant, and said that four months
before her abdomen became enlarged suddenly, that she was un-
able to urinate, and that a large quantity of urine was drawn
off by the catheter, which relieved her condition. A No. 16
(Fr.) male catheter was passed, and fifty ounces of very pale,
clear urine were drawn off. The urine was neutral, with a spe-
cific gravity of 1'002, and contained a small quantity of pus, but
no albumin. The relief was great, the respirations were no
longer gasping, and the face lost its anxious expression. A
soft-rubber French male catheter was passed into the bladder
and kept in place by bands of adhesive plaster. The paralysis
of the bladder was complete, and lasted for a week. It was
found impossible to restore the uterus to its normal position by
manipulation, and the patient was instructed to place herself in
the knee-chest position for five minutes at a time frequently
during the day. At the end of ten days she urinated without
difficulty, and the uterus was restored to its normal position.
Asphyxia caused by a Plate of Artificial Teeth impacted
in the Trachea ; Death. — Dr. Louise S. Blum reported a case
and said that the literature of the subject of foreign bodies in
the air-passages was exceedingly rich in rare and peculiar cases
of extreme interest. Almost every physician had been called
upon, at least once in the course of his practice, to remove some
article from the air-passages of a child, who had made the
mouth, instead of the pocket, a common receptacle. In such
cases there had been found and removed pins, needles, marbles,
fish-hooks, rings, buttons, button-molds, pebbles, sticks, pens,
slate-pencils, ears of rye, wheat, or barley, fruit-stones, seeds,
and numerous other articles. It seemed that this reprehensible
practice was not confined to children, for a number of the arti-
cles mentioned, as well as some others, had been removed in
the cases of men and women. Buckley, for instance, removed
a copper umbrella-tip from the larynx of a man; and, in two
other cases on record, a puff-dart * and a hard rubber tube were
similarly removed. Instances of pieces of the various kinds of
food entering the air-passages during deglutition were of such
frequent occurrence that they received no mention. The fact
that tracheotomy-tubes and corroded pieces of the same, hypo-
dermic needles and various surgical instruments, or portions of
them, broken off during operations, also unsecured corks used
for keeping the jaws apart, leeches carelessly applied, sponges,
etc., had all been found at various times in the respiratory
tract, was of far more importance and interest to the medical
profession. It was scarcely less interesting to read that matters
vomited during anaesthesia, or unconsciousness during apoplexy
or epilepsy, as also regurgitated chyme, curdled milk, worms
from the alimentary tract, pus from tonsillar, post-pharyngeal,
or epiglottic abscesses, necrosed nasal, palatal, and cranial bones
and laryngeal cartilages, had all at various times acted as foreign
bodies in the air-passagee of man. Even a lymphatic bronchial
gland, one inch in length, had been known to cause death by
becoming impacted in the rima glottidis during a violent fit of
coughing. A still more remarkable case was that recorded by
Ruehle in '• Kehlkopfkrankheiten," in which the epiglottis of
a man was drawn into the upper orifice of the larynx during
deglutition, where it became firmly impacted, and, acting as a
foreign body, caused death. During operations upon the teeth
and mouth, one or more teeth or crushed fragments of the same
had frequently fallen into the windpipe. More rarely a num-
ber of artificial teeth connected by a metal baud had become
* See this Journal, November 1, 1884, p. 48V.
218
REPORTS ON THE PROGRESS OF MEDICINE.
[N. Y. Med. Joub.j
dislodged during sleep, and bad been drawn into the larynx or
trachea by the attempts made at respiration. This accident had
also occurred during deglutition, although in that case they were
usually swallowed with the bolus of food and entered the stom-
ach. Still more rarely had this accident occurred where the
teeth were attached to a plate. The only case of the kind on
record, so far as Dr. Blum knew, was that reported by Mr.
Henry G. Croly, of Dublin, cited by Prof. Gross, in which in-
stance seven artificial teeth, set in gutta-percha, were arrested
at the junction of the larynx and trachea. The case which
formed the subject of Dr. Blum's paper was a parallel one, but
was far more peculiar than the majority of such cases were
likely to be, from the fact that the accident occurred in the
course of an acute disease, and was not suspected until after the
death of the patient.
On February 18, 1883, the doctor was asked to call upon Caro-
line N., a widow, aged twenty- five. The patient was examined
carefully; temperature 104° F., pulse 128. Two calls were
made on the following day and the temperature taken in the
morning and in the evening, which, with the previous history
of the case, confirmed the diagnosis of malarial fever of the re-
mittent type.
February 21st the temperature was 103° F., pulse 115. Feb-
ruary 22d, temperature 102° F., pulse 110. Within an hour
after the last visit Dr. Blum was hastily recalled to the patient,
the messenger saying that she was dying of haemorrhage. The
patient, with livid face and convulsed, was being held down by
four people, and as the doctor reached the bedside she gave a
few gasps and expired before anything could be done for her
relief. With the last gasp of the dying woman and the conse-
quent dropping of the lower jaw the loss of the teeth was no-
ticed by the mother, who called the doctor's attention to the
fact; but a thorough search of the room did not reveal them.
A history of the patient's condition and actions just prior to
death convinced Dr. Blum that the teeth had become dislodged
and had entered the air-passages, thus causing death. A post-
mortem examination was made on the next day, and showed
that the heart and lungs, otherwise normal, presented the usual
signs of death from asphyxia. The liver was congested and
softened; the spleen was softened and much enlarged, thus
verifying the diagnosis of malarial fever. All the other organs
were found in a normal condition. The missing teeth were
found in the trachea about two inches below the larynx. The
plate was of the usual size, of vulcanite, and had four teeth at-
tached to it, and was so firmly wedged that force little short of
violence was required to remove it. In the vigorous efforts
made to dislodge the plate, one of the teeth, which was imbed-
ded in the walls of the larynx, was broken off and left behind.
Meeting of June 26, 1885.
Dr. Ohaeles K. Mills in the Chair.
Mart Willits, M. D., Reporting Secretary.
Carcinoma of the Uterus.— Dr. D. W. Barb reported a
case in which the patient had resorted to the " Faith Cure."
Early in January, 1879, he was called to see Mrs. S., forty-six
years of age. She had been suffering at intervals for several
months from severe uterine haemorrhages. A vaginal examina-
tion revealed a cauliflower excrescence which involved the pos-
terior and a portion of the anterior lip of the os; the vagina
was not implicated. An operation was decided upon, and, in
the presence of Dr. C. A. Groff and Dr. I. G. Heilman, the cer-
vix uteri was removed close to the body by means of an ecra-
seur. The wound healed kindly and without any trace of local
trouble, and for two years and a half the patient's health was
good, although she had mental forebodings. At the end of the
third year some haemorrhage occurred, and an examination re-
vealed granulations of a specific character, apparently involving
the entire endometrium. The whole surface was thoroughly
cauterized with Vienna paste, and the symptoms were arrested
for another year, making four- years of vigorous health. Haem-
orrhage again occurred, and an examination revealed a marked
epithelioma involving the vaginal wall. The body of the uterus
was enlarged and also evidently involved. Palliative measures
were resorted to, but there was no hope of eradicating the dis-
ease. The patient was much alarmed, and, although there was
neither pain nor haemorrhage, she gave evidence of speedy dis-
solution. At this point she made arrangements for the "Faith
Cure," sought the prayers of a circle and was anointed, after
which she declared herself cured. Her general condition im-
proved, and when Dr. Barr met her three months later he did
not recognize her, because of the improvement in her appear-
ance. Her health seemed good for about a year, when she
again began to fail, and he was called to see her, after a day of
severe suffering. He found a distended bladder, which was re-
lieved by the catheter. An examination showed that the can-
cer had never been healed nor its progress in any way arrested,
but that it filled the pelvic cavity, and the enlarged uterus
reached above the umbilicus. This increase in size had taken
place in about two years, the growth having steadily progressed
notwithstanding the patient's apparent good health. She died
soon after. The tumor in itself was painless through the entire
period of its growth, death being induced chiefly from its press-
ure upon the neighboring vessels, firm adhesions having formed
between the two.
Dr. Charles P. Turner said, in referring to the " Faith
Cure," that he had known of several cases of nervous inertia
that seemed to be cured by the influence of a strong will over a
weak one, but the benefit was transient. He would believe in
the "Faith Cure " when he saw a case of tuberculosis or cancer
cured by that method.
Dr. E. E. Montgomery said that the class of cases the cure of
which would convince one of the efficacy of the "Faith Cure"
were the very ones that were not treated in that way. He in-
stanced the case of a lady with organic disease of the heart who
applied for treatment by this method, and was told that her
case was not a suitable one for that form of treatment.
geports on tbe progress of fftetrichte.
OTOLOGY.
By CHARLES STEBMAN BULL, M. B.
Disease of the Nervous Apparatus of the Ear. — Kipp (" Arch, of
Otol.") reports three cases presenting, in connection with Meniere's
train of symptoms, certain uncommon features. The first case was that
of a man, aged forty-eight, who had been totally deaf in his right ear
since infancy. In this case Meniere's train of symptoms had been pre-
ceded by a febrile paroxysm and followed by neuralgia and erysipela-
toid inflammation of the ear. The case resulted in partial recovery of
hearing. The facts that the hearing of the left ear was very acute be-
fore the initial chill and that absolute deafness was rapidly developed
without the slightest objective signs of disease of the middle ear make
it tolerably certain that this case was one of primary disease of the
nervous apparatus of the ear. The process was probably inflammatory,
which started in the cerebral meninges at the base, and thence spread
to the labyrinth and afterward to the Gasserian ganglion. This view of
the probable seat of the disease is strengthened by the fact that the hear-
ing for speech was partially restored, while deafness for low tones re-
mained.
August 22, 1885.]
REPORTS ON THE PROGRESS OF MEDICINE.
219
The second case was that of a man, aged forty-one, in whom M6ni-
dre's train of symptoms was followed by neuralgia and erysipelatoid
inflammation of the face. It was impossible to say how much of the
deafness was due to chronic middle-ear disease. There can be no
doubt, however, that, after the attack of roaring in the ear, the hearing
was rapidly destroyed.
The third case was that of a woman, aged fifty, in whom there was
sudden, complete, and permanent destruction of hearing of one ear, fol-
lowing a tremendous roaring in the ear. Politzer's acoumeter was heard
two inches from tins ear when the other ear was open, but not at all
when this was tightly closed. The watch was not heard when pressed
against the auricle or the mastoid. Large tuning-forks of different
pitch were not heard when held before the external meatus, but, when
placed on the mastoid, were heard in the other ear. The hearing of the
right ear was perfect. There was nothing abnormal in the external
canal or the drum-membrane of either ear. There was no pharyngeal
catarrh. The absence of marked vertigo was a noteworthy feature of
this case, and would seem to make it probable that the disease was con-
fined to the cochlea.
Caries of the Temporal Bone. — Sutphen (Ibid.) reports two fatal
cases of this nature in which openings were made through the roof of
the tympanum. The first case was that of a man, aged forty-four, who
had suffered from otorrhcea for twelve years. The autopsy showed an
immense abscess occupying nearly the whole of the anterior and middle
lobes of the left hemisphere, containing a dirty-brown, foetid pus. The
opening made by the operation extended into the cranial cavity on the
superior surface of the petrous bone, just in front of the superior petro-
sal sinus. In the depression just external to this a circle of dead bone
appeared. To this the dura mater was attached, and perforated by a
small circular ulcer. There was some localized meningitis. The in-
strument used at the operation had pierced the dura and entered the
cavity of the abscess, but the flow of pus was prevented by the soft
brain-substance or the dura itself acting as a valve.
The second case occurred in a man, aged twenty-one, who had had
otorrhcea for ten years, with an acute attack of inflammation of two
weeks' duration, which was evidently intra-cranial. The right external
rectus was paralyzed, and there was choked disc in both eyes, with im-
paired vision. The patient lived ten days after being seen. On the
day of his death an incision was made upward through the swollen tis-
sue in the external auditory canal. A probe inserted through this cut
passed over bare bone, slipped into a carious passage, and entered the
cranial cavity. This bony sinus was enlarged with a trocar, but no pus
escaped. The patient died comatose. At the autopsy the right lateral
and superior longitudinal sinuses were found occupied by a large and
partially organized clot ; the walls of the sulcus were carious ; circum-
scribed meningitis existed near the temporal bone, and there was soft-
ening on the surface of the middle lobe. The opening into the cranial
cavity was found in the depression just external to the eminence for the
superior semicircular canal, surrounded by carious bone. No accumula-
tion of pus was found. The caries in the temporal bone involved the
walls of the tympanum and the mastoid.
The Position of Reissner's Membrane in the Human Cochlea. —
Steenbriigge (Ibid.) describes the results of his investigations upon
Reissner's membrane in a very interesting paper. In a woman, aged
thirty-four, who had died of tuberculosis, he found in the anterior lower
wall of the left utricle, at the level of the lower margin of the fenestra
ovalis, an elliptical perforation, measuring 1 >< H mm., which consti-
tuted a communication between the perilymphatic and endolymphatic
spaces, which probably existed during life. In the cochlea of the same
side, particularly in the second and third turns, there was a consider-
able deposit of haemoglobin, with great dilatation of the vessels, which
had ruptured at several places, causing extravasation of blood. There
was also a peculiar condition of Reissner's membrane, which, owing to
the draining off of the endolymph, sank down on the membrana tec-
toria and organ of Corti, in consequence of an excessive pathological
Stretching or relaxation. If the sinking down and apparent agglutina-
tion of this membrane had occurred during life, the function of the
organ of Corti and of the membrana tectoria must have been impaired.
If the elasticity of Reissner's membrane is acknowledged, the conclu-
sion seems permissible that, in the human cochlea, a post-mortem re-
laxation of the vestibular membrane or loss of elasticity occurs in some
instances, while in others it may be wanting or be present in a lesser
degree. We thus see that the angle formed by Reissner's membrane
in the pathological or histological specimen is in no definite relation to
the curved shape it probably has in life.
The Terminal Cupule of the Ear. — Coyne and Ferre' (" Ann. des
mal. de l'oreille et du larynx ") have been making some anatomical and
physiological investigations upon the terminal cupule of the ear of some
of the lower animals. The cupule is situated above the auditory crests
and projects into the ampulla? of the semicircular canals. It appears
like a brilliant, refracting corpuscle, of semi-hard consistence, at the
posterior and superior part of the ampulla. Under the microscope it
appears granular, refracting, and striated, presenting bands which are
alternately bright and shaded. The number of terminal cupules found
in a pyramid corresponds to the number of ampullae. Their shape
varies according to the shape of the auditory crests. The latter con-
sist of several layers: 1. A layer of connective tissue traversed by
vessels and nerves. 2. A special membrana propria. 3. A basement
membrane. 4. An epithelial membrane formed of two layers. The
auditory hairs play a double role of protection and of regulation of the
ciliary vibrations through the medium of the terminal cupule. The
entire apparatus seems to be one of accommodation for sonorous vibra-
tions, and is also extremely well adapted for the perception of the
irregular vibrations which constitute noise. The membrane of Corti is
analogous to the cupule in its structure and relations, and it seems to
act physiologically in the same way in regulating the vibrations of the
cilia of the cells of Corti.
Traumatic Haemorrhage into the Internal Ear. — Hardwicke (Ibid.)
reports a case of this kind in a lad, aged seventeen, who was brought
to the hospital at Sheffield completely deaf in one ear ; the deafness
had occurred four days previously from a blow on the side of the head
with a cricket-ball. The watch could not be heard in the right ear,
neither could the tuning-fork. Nothing abnormal was found in the
pharyngeal mucous membrane or the middle ears. A diagnosis was
made of haemorrhage into the cochlea or semicircular canals. The
treatment consisted in the application of leeches to the tragus, a blister
behind the ear, and potassium iodide internally. The patient left the
hospital cured on the eighth day.
Two Rare Cases of Mechanical Injury to the Organ of Hearing.
— Moos (" Arch, of Otol.") reports a case of bilateral labyrinthine dis-
ease in a man, aged twenty-six, which was developed fifteen minutes
after a stay of thirty hours in a diving apparatus. It manifested itself
by nearly total deafness in both ears, tinnitus aurium, and vertigo, fol-
lowed by staggering gait and inability to stand without support. It
was caused by suddenly leaving the diving apparatus, after working in
it, under a pressure of two atmospheres with but short intermission, for
thirty hours. These symptoms were probably the result of a haemor-
rhage in the labyrinth. The second case was in a man, aged thirty-
four, in whom both drum-membranes were ruptured by the compression
of air produced by the explosion of chlorophthallie ether during the
making of eosine.
Loss of Hearing from Mumps. — Kipp (Ibid.) reports one case of
this disease, in a young man aged eighteen, in which the total loss of
hearing was in the right ear only, which was first noticed fifteen days
after the commencement of an attack of mumps, while the patient was
suffering from a metastatic inflammation of the left testicle. As all
signs of irritation of the acoustic nerve were absent, it seems highly
probable that the disease was limited to the cochlea. Whether the
morbid process here was an inflammation with serous or haemorrhagic
effusion or embolism of the cochlear artery, it is difficult to say. Kipp
thinks that an extension of the disease from the parotid gland to the
ear along the facial nerve, or through the external canal and tympanic
cavity, seems highly improbable ; he thinks it much more likely that
the inflammation of the parotid, the orchitis, and the ear affection
are merely local expressions of the same morbid condition of the
blood. Another case was similar to the first, except that there was
no orchitis.
Chiseling of the Mastoid Process. — Hartmann (Ibid.) reports in
detail the histories of fourteen cases in which it was necessary to open
the mastoid process, and lays down rules for the performanoe of the
920
MISCELLANY.
[N. Y. Med. Joca.,
operation. The incision in the skin and the opening in the bone should
be practiced at the line of attachment of the auricle, or at least imme-
diately behind it. The possibility should always be borne in mind that
in operating we may chance upon a sharp curve of the transverse sinus.
The skin incision and the bony canal should be made so large that a
free inspection of the wound cavity may be possible during the after-
treatment. In order to keep the wound open, rubber tubes should be
inserted immediately after the operation, to be replaced subsequently
by thick and still later by thin lead ones.
Bound-Cell Sarcoma of the Ear. — Green (Ibid.) reports an interest-
ing case of tliis kind occurring in a man aged twenty-three. There
had been a discharge from the left ear for seventeen years, following
an attack of scarlatina. When the patient was first seen there was a
muco-purulent discharge, and a spongy, very vascular, fleshy mass filled
the left meatus, and seemed to be adherent to the wall. The left auri-
cle was pushed outward and forward by a diffuse swelling over the
mastoid, which had ruptured, and from the opening protruded a mass
of fungous granulations two inches in length, dotted with spots of
sloughing tissue, and bleeding freely on being touched. The meatus
was filled with the above-described fleshy mass. Three days later the
fungous granulations over the mastoid were removed, and the swelling
was incised down to the bone, setting free a large amount of fluid and
caseous pus. The bone was found extensively softened, and a large
opening was made with a gouge in the mastoid antrum. The meatus
was cleared from granulations, and carious communications were found
to exist between the meatus and the mastoid. The case did well for a
time, and, then the bad symptoms reappeared, abscesses formed in the
auricle and neck, and the growth returned and rapidly increased in size
until it measured eight inches long, six wide, and four thick, and ex-
tended downward and in front of the auricle. Large masses sloughed
away at times, giving rise to repeated haemorrhages. The patient died
from exhaustion about six months after the first operation.
Fracture of the External Auditory Canal by Contre-coup, with
Eupture of the Drumhead. — Williams (Ibid.) reports an interesting
case of this nature in a man, aged thirty-seven, who, while walking on
a slippery sidewalk, lost his footing and fell backward, striking the
back of his head against the ice with such force as to stun him. He
remained for a time unconscious, vomited freely, and lost a large
amount of blood from the ear. A splinter of bone from the auditory
canal, not entirely detached, protruded through the skin. There was a
stellate laceration of the raembrana tympani. The piece of bone was
removed with the forceps and measured 4 mm. by 3 mm. at its broader
end, tapered to a point, and had a smooth periosteal surface on one
side and a rough surface on the other. The patient eventually recov-
ered, and the rupture in the drumhead healed. The fracture probably
extended into the Glaserian fissure and terminated at the foramen lace-
rum medium. There was, no doubt, concussion of the entire labyrin-
thine contents, with a localized pachymeningitis.
Limited Caries of the Fundus as a Frequent Cause of Obstinate
Otorrhoea. — Woakes ("Ann. d. mal. de l'oreille et du larynx ") has a
recent article upon this subject which may be summarized as follows :
Certain cases of otorrhcea are very rebellious to treatment, and in these
cases an examination will usually show the presence of granulations on
the drumhead or in its immediate vicinity. This granulation tissue
originates in the tympanic cavity, and by touching it with a probe there
is felt a slight sensation of rugosity, the sign not only of simple hyper-
trophy, but of a carious process at some limited point of the bony wall.
This explains the persistence of the otorrhoea. To combat this condi-
tion, Woakes employs a solution of sulphurous acid, with which he pro-
fesses great success. The agent employed seems to dissolve the earthy
salts in the particles of dead boue and to disinfect the diseased surface.
It also acts as a stimulant to the process of cicatrization.
The Operative Treatment of Congenital Malformation of the Auri-
cle.— Stetter (" Arch. f. Ohrenheilk.") reports in detail a case of de-
formity of the auricle as follows: The deformity consisted in the auri-
cle being bent from above and behind downward and forward over the
opening of the external canal, so that no sound-wave could enter the
canal directly, which could only be looked into from below. The opera-
tion consisted first in dissecting up a triangular flap of skin, with the
apex upward and the base on a level with the attachment of the auricle,
and in dividing the subcutaneous cellular tissue by many small trans-
verse incisions. It was then possible to lift up the apex of the auricle
and to fasten it by sutures to the skin covering the squamous bone. To
make this firm and lasting, two parallel incisions, 3 cm. long and 1 cm.
from each other, were then made from the posterior surface of the
auricle upward and backward toward the squamous bone. This flap of
skin was then dissected carefully up with the subcutaneous connective
tissue, and drawn forcibly upward, and by this duplicature of skin the
new location of the auricle was made fixed and permanent. Both raw
surfaces of this fold of skin, at the base and its further extension,
were then united by sutures, and a firm bandage, with pressure on the
helix, was applied. The result was satisfactory.
Diseases of the Ear in Typhoid Fever. — Bezold (Ibid.) recognizes
three varieties of disease of the ear in the course of typhoid fever, viz. :
1. Hardness of hearing, without signs of inflammation and without any
symptom in the drumhead or tympanic cavity, which seems to be due
to some central changes. 2. Closure of the Eustachian tube with con-
secutive sinking of the drumhead. 3. Purulent inflammation of the
drum-cavity, either without perforation or with perforation of the drum-
membrane, and otorrhcea. The so-called nervous deafness is charac-
terized exclusively by subjective symptoms, varying and moderate deaf-
ness, and tinnitus. As regards the affection of the Eustachian tube, he
does not think that it occurs more frequently in typhoid-fever patients
than in healthy persons. Both these varieties of disease are met with
in the beginning of the fever, but the inflammatory disease of the mid-
dle ear occurs toward the end of the abdominal affection. The results
of the autopsies were as follows : 1. A glairy mucus in the Eustachian
tube was found in six cases. 2. Secretion in the drum in four cases.
3. Simple hyperamiia of the mucous lining of the drum in two cases.
4. Succulent swelling of this mucous lining in three cases. 5. Succu-
lent swelling and extravasalion of blood in a circumscribed spot of the
mastoid cells in one case. 6. Extravasation of blood in the drumhead
in two cases. 7. Perforation of the drumhead in two cases. 8. Noth-
ing abnormal in two cases. Bezold considers that the purulent otitis
media met with in typhoid fever may arise in three ways : 1. The direct
propagation of the inflammation of the naso-pharynx through the Eus-
tachian tube. 2. The introduction of septic material from the naso-
pharynx directly into the middle ear. 3. Emboli of the vessels of the
mucous membrane of the middle ear, from endocarditis and thrombus
of the left side of the heart, or from purulent deposits at the periphery.
Clonic Spasm of the Levator Palati which produced a Rhythmic
Ticking Noise. — Williams (" Zeitsch. f. Ohrenheilk.") reports a rare
case of this kind in a well-developed girl of twelve years of age, in
whom the affection was in all probability connected with chorea. The
noise was probably produced by the vacuum which was caused at the
moment when the upper surface of the velum separated from the roof
of the naso-pharynx, with which it was brought in contact by spasmodic
contraction. Williams had an opportunity to watch the velum during
an attack of acute amygdalitis, and found that the ticking noise was
absent, although the spasm of the levator was still present.
HI i s 1 1 1 1 a n 2 .
The International Medical Congress. — The " Medical News " pub-
lishes the following letter from Sir James Paget, dated London, July
22, 1885:
" Dear Dr. Hays : I am very sorry to learn from some of your
journals, as well as from letters which I have received, that there are
serious differences of opinion among the members of our profession in
your country as to the arrangements to be made for the International
Medical Congress which it is proposed to hold in Washington in 1887.
The deep interest which I feel in the Congress makes me venture to
write to you in the hope of helping toward a right decision of some
of the questions in dispute, and chiefly by stating what I believe to
have been the custom at former meetings.
" I believe that a principal question relates to the authority, if any,
August 22, 1885.]
MISCELLANY.
221
which was given by the Congress at Copenhagen in- 1884 to the gentle-
men who conveyed the invitation that the next meeting should be held
in the United States of America.
" I believe that it has never been considered that the members at
one Congress should give any formal authority for any part of the or-
ganization of the next. At each meeting some place has been named
at which it was deemed desirable that the next should be held ; and at
the same time, or soon afterward, some persons of high repute in that
place have been asked to take such steps as they might deem necessary
or most likely to promote a successful meeting.
" Thus, after the Congress at Amsterdam in 1879, the president, Prof.
Donders, wrote, in the first instance to Sir Joseph Lister and Sir Will-
iam Bowman, and by them, and those whom they asked to act with
them, the first and all the principal subsequent measures were adopted
for the promotion of the meeting in London. Sir Risdon Bennett, the
chairman of the Executive Committee, communicated to Prof. Hanno-
ver and Prof. Panum, of Copenhagen, the desire that the next meeting
might be in one of the chief cities of Scandinavia ; and those gentle-
men, and others acting with them, began and had the principal part in
all the arrangements for the Congress in Copenhagen.
"I fully believe that it was understood at Copenhagen that the same
course would be pursued in the organization of the Congress to be held
at Washington. I was at the general meeting at which, after some dis-
cussion, the majority of the members present expressed the wish that
the next Congress should be in the United States ; and I have no doubt
that it was expected that the distinguished American gentlemen there
present would obtain the co-operation of the most eminent of their
professional brethren, and would, with them, make all the arrangements
which they should deem best.
" Certainly it was not supposed that the Congress would be regu-
lated, with any degree of exclusiveness, by the members of one medi-
cal association, however numerous ; and I think it quite as certain that,
if this had been thought possible, the proposal that the next meeting
should be held in the United States would not have been adopted.
" I am sorry, also, to feel sure that if the Congress be not sup-
ported by the eminent men who have now declared that they will take
no part in it, the members of the profession in this country who will
attend it will be very few. And in this opinion, as well as in all that I
have written here, I have the concurrence of several of the most influ-
ential of the London Congress with" whom, before this writing, I con-
sulted."
Editorially, the " News " says :
" We invite careful attention to a letter appearing in another col-
umn, which has been received from Sir James Paget, who, as the imme-
diate predecessor of the lamented Panum in the presidency of the Con-
gress, and as a member of the existing Executive Committee, speaks in
reference to the organization of the next Congress with the highest
authority. This letter commends itself to the thoughtful consideration
of every physician who has the true interest of the American profession
at heart, and it will give light to some who desired more authoritative
information than they have yet possessed to guide correctly their future
course of action.
" It has been asserted by the editors of one or two medical journals
that the Executive Committee of the last International Medical Congress
no longer exists, that therefore the Congress must meet next in this
country, and hence that the American Medical Association plan must
be adopted and supported. We have now information from members
of the Executive Committee of the Copenhagen Congress that that com-
mittee is considered to be still in existence, that it still has work to do,
and that it will by no means hesitate to assume the responsibility of
ordering that the Congress shall meet in Europe instead of this country
in 1887, in case it considers that such change of place of meeting would
be for the interests of the Congress. And, if it does issue such a no-
tice, there can be no doubt that it will be obeyed.
" Of this committee Sir James Paget is one of the most prominent
and influential members, and hence his opinion demands the most seri-
ous consideration. This opinion is clear and straightforward. ' Cer-
tainly it was not expected that the Congress would be regulated with any
degree of exclusiveness by the members of one medical association, how.
ever numerous, and I think it quite as certain that, if this had been
thought possible, the proposal that the next meeting should be held in the
United States would not have been adopted. I am sorry, also, to feel
sure that, if the Congress be not supported by the eminent men who
have now declared that they will take no part in it, the members of the
profession in this country who will attend it will be very few.'
" We consider it as now certain that the European members of the
Congress have, through their Executive Committee, the power to prevent
any material interference with the organization and work of the Con-
gress itself, but, while this does away with our fears lest the progress
and usefulness of these great international scientific gatherings should
be checked by the action in this country, it increases our anxiety as to
the effect of this discord upon our reputation abroad, and on our asso-
ciations at home.
"The action of 'the original committee — of the American Medical
Association — and of the new committee, is now generally understood ;
and there does not seem to be much use in further comment and criti-
cism upon what is past. The important question now is as to the fu-
ture. Is there any way by which the impending disgrace can be
averted ? If there is, it must be such as will induce those who have
withdrawn from the organization to return and co-operate heartily. To
the best of our knowledge and belief, derived from an extensive corre-
spondence and from personal interviews, there is but one way to do
this, viz., by dropping the code question entirely, confirming all the
appointments of the original committee, and leaving to the enlarged
committee which it created, including the presidents of the sections, the
work of making additional appointments, completing the organization,
and carrying out the work to its completion. If this be done, we be-
lieve that questions of appointments, etc., will be settled to general
satisfaction, and that, although the difficulties of the work will be
greatly increased, the Congress will be, what we all desire it should be,
a great success.
"If this be not done, we do not believe that the Congress will meet
in this country in 1887."
The " Boston Medical and Surgical Journal " says :
" It has been evident for some time that the prospect for a success-
ful international congress in this country was very small. It is impos-
sible to expect men of scientific attainments to cross the water to take
part in a congress about which there is so much misunderstanding as
in the present instance. It is exceedingly unpleasant to accept hospi-
talities in a house whose inmates are unable to agree as to the manner
in which such hospitality shall be shown.
" We are permitted to-day to print a letter from a medical gentle-
man, well known on this side of the water, which expresses the attitude
which men, interested in the science and not at all in the politics of
medicine, must necessarily take. The letter is addressed to Dr. J. Col-
lins Warren, and is as follows :
" ' London, 13 Harley Street, July 85, 1885.
" ' My Dear Collins Warren : I have seen in medical papers, and
heard through private sources, that a serious disagreement has occurred
in respect to the organization of the ensuing International Congress in
Washington. A few of those who had been concerned in organizing
the London Congress recently met to talk the matter over, for we feel
that any failure which might attend the Congress in the United States
would be little short of a professional disaster. I do not myself think,
and most here would share my opinion, that a congress from whose
ranks some of your best physicians and surgeons have determined to
withdraw, and whose members are to be further restricted to such as
belong, either directly or by affiliation, to one medical body in America,
would be likely to be attended by many colleagues from this country.
" ' Speaking from personal knowledge, an international congress can
not be a success unless taken up in the warmest and most self-sacrific-
ing manner by all the principal men in the country where it is to be
held. I was present at the meeting in Copenhagen, where the invita-
tion to meet in America in 1887 was given, and after some discussion
accepted. I am sure it was present to the mind of every one there that
the invitation was one from the profession of America, and not from
any section of it, or any particular medical society in it. Otherwise, I
I feel pretty certain Prof. Virchow's invitation to meet on the next
occasion in Berlin would have been accepted.
222
MISCELLANY.
[N. Y. Mkd. Joub.,
" 1 Even now it would appear to me wiser to have that invitation
renewed, or to meet in some other place, than to have a meeting in
America, from which, so far as we may at present judge, many of the
chief men on both sides of the Atlantic would absent themselves. You
•re at liberty to use this letter as you deem fit.
" ' Yours very faithfully,
" ' William MacCormack.'
" It is not easy to see how the matter can be remedied so as to
counteract the disagreeable impression already made upon foreigners.
What the committee may be able to accomplish at its extra meeting in
September can only be conjectured, but we are very skeptical as to
their power to accomplish any good results. Certainly nothing can be
expected from men who consider the numerous resignations that have
taken place as manifestations of a conspiracy, or as part of a game of
bluff. We trust the editor of the ' Journal of the American Medical
Association ' will be able to comprehend, at least, that the opinion rep-
resented by the above letter is not the expression of those who have
' deliberately undertaken to obstruct the work of organization.' "
The " Progres medical " says : " We learn by the ' Medical Times '
that the organization of the International Medical Congress at Wash-
ington is meeting with certain difficulties among our confreres beyond
the sea. The American Medical Association disapproves of the acts of
the committee named at Copenhagen, although the latter had joined to
itself a great number of members of the association. It preferred to
replace the committee by another made up wholly of its own members.
It would be ungracious in us to criticise the honorable medical associa-
tion of the United States in any way, but it is incontestable that this
way of acting is contrary to the usage followed by the International
Medical Congress thus far, and, as the 'Medical Times' very justly says,
it involves great risk of compromising the success of these interna-
tional reunions for ever. What is none the less certain and none the
less grave is, that thus many of the American members who are held
in the highest esteem here, and enjoy the deepest sympathy, would be
alienated from the Congress. However attractive it would be for us to
extend the circle of our acquaintance and to contract new relations, we
should be quite a s well pleased to see again those whose names have
long been known to us, and whom we are proud to call our friends.
There is no doubt that any indignity put upon them will considerably
chill the zeal of their Old- World colleagues in trusting themselves to
the uncertain waves of the ocean."
The " Journal of the American Medical Association " says :
" Evidences are not wanting that the principal performers in the
grand comic play of ' Much Ado about Nothing,' which was commenced
so brilliantly on the 29th of June by twenty-eight prominent members
of the profession in Philadelphia, are becoming weary of their work.
Some who were induced to join in the play from the first impulse have
already withdrawn, and others are evidently preparing to follow.
" Dr. John H. Packard, of Philadelphia, who was appointed secre-
tary-general of the Congress by the Committee of Arrangements at the
meeting in Chicago, and whose name was published as one of the
twenty-eight who declined to accept any place in the revised organiza-
tion, has recently withdrawn his declination and accepted the position.
As an offset to the other twenty-seven who started the scheme of ob-
struction and factious opposition in that city, we have the names of
seventy prominent members of the profession in the same city who
have freely indorsed the action of the American Medical Association,
and pledged their support to the organization of the International
Medical Congress of 1887. Among them are the names of teachers
and authors as eminent and as well known, both in this country and in
Europe, as any of those who so hastily declined. To the same indorse-
ment and pledge are appended the names of several hundred prominent
and well-known members of the profession in other parts of the State
of Pennsylvania.
"For further evidence of public sentiment in the same direction,
the reader is referred to the resolutions in the present number of the
journal, passed by a joint meeting of the Northeastern and Northwest-
ern Ohio Medical Societies, which embrace the profession in about forty
counties of that State.
" The idea that the Committee of Arrangements will not be able to
complete the work of preliminary organization at its coming meeting on
September 3d, or that the vacancies in the several sections can not be
filled with men of the highest standing and ability, is simply absurd.
And, if the changes are made in the rules that were indicated in the
journal of August 8th, there will not be left the vestige of a foundation
on which opposition can rest, except that afforded by personal prejudice
alone."
The British Medical Association and the American Medical Asso~
ciation compared. — " A statement was made in a recent issue of this
journal," says the " Maryland Medical Journal," " that the profession
in the United States greatly needed a national scientific association that
was capable of meeting all the requirements of a vigorous and intelli-
gent scientific organization.
" For some years past the American Medical Association has at-
tempted to represent the interest of scientific medicine in this country.
Quite recently the profession has been made aware of the fact tliat the
American Medical Association is totally incapable of dealing with seri-
ous and important medical interests. Whatever value it may have to
the medical profession, it is a serious fact that interests of the profes-
sion are not subserved by the association in a manner to give entire
satisfaction. There are serious defects somewhere in its organization
and conduct, and, unless these are plucked out, the association will re-
main a crippled and feeble scientific organization. The faults which
exist in the plan and government of the association must, in our judg-
ment, be corrected before it can take a healthy, vigorous, and intelli-
gent grasp upon the profession, and before it can rise to the highest
aims and purposes of a national medical organization. It is not our
purpose to suggest remedies for the ill-health of the association, but
we propose to show by way of comparison that the association is in an
unhealthy physical and mental condition. We will permit some of our
exchanges to make a diagnosis of the pathological condition which is
undermining the vitality of the association and to suggest the appropri-
ate treatment.
" We have before us the Annual Report of the Council of the Brit-
ish Medical Association, which was presented to this body at its fifty-
third annual meeting, held July 28th, 29th, 30th, and 31st. From this
report we are able to present a number of useful and suggestive facts
relative to the highly prosperous and progressive condition of the Brit-
ish Medical Association, a scientific body which bears pretty much the
same relations, ostensibly, to the profession in Great Britain that the
American Medical Association claims to do to the profession of the
United States.
"This report says that on July 1, 1884, the membership of this
association numbered 10,826; of these, 123 have since died, and 162
have resigned; 708 members have been elected during the year, leav-
ing a total of 11,249 members on the roll of the association on
June 16, 1885. This report also states that the revenue of the asso-
ciation for the year ending December 31, 1884, was £22,256 and the
surplus after paying expenses was £2,319. The total invested funds
of the association, exclusive of trust funds, amounted to £19,541.
The association owns and publishes the " British Medical Journal," a
publication which enjoys not only a high reputation at home, but
throughout the world. Apart from the valuable work the association
journal is doing for the profession in Great Britain, the association
expends a large sum of money each year in promoting original research
and in advancing scientific medicine.
"The association has organized various branches in different sec-
tions of Great Britain, which add largely to its efficiency and prosperity.
The various committees appointed by the association have charge of all
questions which affect public and professional interests. It is safe to
say that no medical organization is doing more to elevate the standard
of scientific medicine and to promote the best interests of the medical
profession than the one under consideration.
"As we see the machinery of the British Medical Association in
operation and observe its movement, we are reminded of the power and
effectiveness of thorough organization, and its vast possibilities when
guided by intelligence and sound judgment.
" The British Medical Association owes its prosperity to the fact
that its whole organization is based upon an active and intelligent prin-
ciple. It exists for the entire profession in Great Britain, and its con-
August 22, 1885.]
MISCELLANY.
223
duct is regulated by the highest aims and needs of the profession. Men
who seek honors at its hands do so in obedience to high principles and
motives. The- association does not exist to give prominence to men
who can only reach prominence through its agency. It is not a politi-
cal or sectional body that flips about over the country at the bid of a
few hospitable members. Its aim and purpose is strictly scientific. Its
members take a pride in promoting its best interests from the fact that
the association is promoting the very highest professional interests.
" Let us consider, by way of contrast, the American Medical Asso-
ciation.
" This association has been in existence since the year 1847. It has
an average membership of less than three thousand. It owns little or
no property. It has done but little to promote original research, and it
has not been able to grasp hold of the various questions which interest
the American profession. The association has a code of ethics, which
has probably (?) done more for the profession than anything else, but,
apart from this feature of regulating ethical questions, it has nothing
to proclaim to the world as worthy of high respect or consideration.
The annual meetings of the association may possibly do good in a social
and semi-scientific way. These gatherings at times have been enjoyable
reunions, and we believe tend to promote good feeling, to create friend-
ship, and to elevate the professional tone. But we ask, Is there not a
serious and important work for a national medical association to do ?
Are there not scientific and professional interests in the United States
which can only be promoted by a national association ? The medical
profession in the United States now numbers between sixty and seventy
thousand members— about double that of Great Britain, we believe.
Many of these men are practicing medicine in the most ignorant and
unscientific manner. The public and the profession is being ignomini-
ously wronged by the herds of quacks that flood our land. With no
organized power to deal with the important relations of scientific medi-
cine to society, the medical interests of this country are annually going
from bad to worse. We repeat, Shall we have a vigorous, intelligent
national medical association, or shall we continue to follow the fortunes
of the one which is ill from its own incapacity and sluggishness and
which has, of late years, manifested little strength beyond that for log-
rolling and wire-pulling for its high honors? Shall the American Medi-
cal Association be reorganized and thus be lifted out of the rut of de-
generacy into which it has fallen, or will the scientific minds in the pro-
fession establish a national association capable of meeting the require-
ments of an enlightened and scientific body of medical practitioners ?
These are serious questions for professional consideration at this time.
Who will answer them ? "
Good Health results from Sanitary Work. — Under this heading,
the secretary of the Michigan State Board of Health, Dr. Henry B.
Baker, of Lansing, says :
" Sanitary authorities have maintained that the sanitary work which
they have recommended to be done as a preparation for cholera — such
as preventing and abating nuisances ; attending to drains, sewers,
privies, and cesspools ; cleaning up generally, and unusual carefulness
in regard to foods and drinks — would reduce the sickness and deaths
from other diseases, even if cholera did not come. The weekly reports
for July, 1885, to the Michigan State Board of Health, by physicians in
different parts of the State, indicate that this is being realized in Michi-
gan so far as relates to the lessened sickness — it having been lessened
from nearly every disease, and greatly lessened from fevers and from
diarrhoeal and other diseases, believed to be especially influenced by
sanitary conditions ; and this is true notwithstanding the meteorological
conditions in that month were rather more than usually unfavorable to
health. It is proper to state, however, that the sickness in any month
is influenced by the meteorological conditions in the preceding month,
and that the meteorological conditions in June, 1885, were favorable to
health.
" Observations in Michigan for many years have shown that in July
the meteorological conditions especially unfavorable to health are, high
temperature, excessive humidity of the atmosphere, and deficiency of
ozone. The bulletin of health in Michigan, July, 1,885, says : ' For the
month of July, 1885, compared with the average of corresponding
months for the seven years 1879-85, the temperature was slightly
higher, the absolute and the relative humidity were more, and the day
and the night ozone were less.'
" ' Compared with the average for the months of July in the seven
years 1879-'85, remittent fever, intermittent fever, dysentery, con-
sumption of lungs, cholera infantum, diarrhoea, cholera morbus, mea-
sles, and whooping-cough were less prevalent in July, 1885.'
" A large part of this decrease in sickness has undoubtedly been
due to the medical and sanitary journals and the newspapers, which
have constantly kept before the people the necessity for sanitary work
and the facts as to the spread of cholera in Europe.
" It remains to be seen to what extent efforts for the exclusion of
cholera from this country, and the general preparation for cholera by
boards of health and the people, shall prove effectual ; but, even if
cholera shall not be entirely prevented, there will remain the belief that
the measures which have so greatly decreased the sickness from other
diseases can not but have had their influence in decreasing it ; and, if
cholera does not occur in this country, it seems quite probable that, by
reason of the suffering elsewhere, there may be as many cases of seri-
ous sickness prevented in this country as there have been cases of
cholera in Europe. But this may not continue without continued vigi-
lance and effort."
Dr. Baker supports his remarks with the following tabular state-
ment :
Health in Michigan in July, 1885, compared with the average in July
for the seven years 1879-85 :
Diseases arranged in order of
greatest diminution of sick-
ness in July, 1385.
PER CENT. OF
ING PRESENC1
In JuJy, 1885.
REPORTS, STAT-
I OP DISEASE.
Average in
July, 1879--85.
Per cent, of re-
ports more (+)
or less (— ) in
July, 1885, than
the average for
July, 1879-'85.
30
51
- 21
15
32
- 17
65
82
- 17
Consumption of Lungs . . .
48
63
— 15
20
33
- 13
62
74
- 12
39
49
- 10
8
17
- 9
14
22
- 8
10
16
— 6
10
15
— 5
11
16
— 5
41
46
— 5
59
64
- 5
Inflammation of the Kidney
17
21
- 4
11
14
— 3
Typhoid Fever
6
8
- 2
Membranous Croup
1
2 .
- 1
0
1
- 1
Inflammation of the Bowels
16
17
— 1
18
19
— 1
Erysipelas
21
22
— 1
58
59
- 1
6
6
Inflammation of the Brain
6
6
Cerebro-spinal Meningitis .
8
5
+ 3
36
32
+ 4
" It will be seen that there was less sickness than the average for
July from nearly every disease reported. From only two, cerebro-spinal
meningitis and tonsillitis, was there an increase."
Elastic Electrodes. — It is often convenient to use large surface
electrodes, and it is desirable that they be so made as to adapt them-
selves readily to inequalities of the surface. Zinc, lead, and various
other materials have been used for the purpose, and have been found
to answer tolerably well, but they are simply flexible, and not elastic ;
consequently they do not recover their flat shape after being used, and
some of them are open to the objection that they are uncomfortable for
the patient to lie upon, while in others the metallic portion is quite
small in comparison with the extent of sponge attached to them, so
that the current is not so diffused as is sometimes desirable. To reme-
dy these defects, Dr. James Craig, of Jersey City, has hit upon the
expedient of using electrodes made of woven brass wire nickel-plated.
224
MISCELLANY.
[N. Y. Mkd. Joob.
Dr. Craig has shown us a set of these electrodes, and it is certainly to
be said of them that they seem admirably calculated to do away with
the objections we have mentioned.
Cholera in India.— Under date of July 6th, the Bombay corre-
spondent of the London " Medical Times and Gazette " says : "I have
again to notice a considerable increase of cholera in Quettah and the
adjoining districts. The cantonments have had to be evacuated, and
the troops placed in tents at a distance from the place. The works on
the railway under construction have had to be suspended until the
abatement of the disease. The cholera is now raging virulently at Kur-
rachi. It is all very well for the promulgators of the non-contagion
theory to stick blindly to a view which can never hold for a moment
where both sides of the question are duly represented. In the case of
the Quettah epidemic there is little room for doubt that the cholera
was carried by human intercourse from Bombay, which now may take
rank as an 'endemic area.' "
The New York Post-Graduate Medical School and Hospital. —
In the " Announcement," recently issued, we find the following grati-
fying statement : " The fourth year of instruction begins on September
12, 1885. The faculty have found their new building very well adapted
to the purposes of a school for advanced medical instruction, a dispen-
sary, and hospital. This large structure is situated in one of the
healthiest locations in the city, very near to Gramercy Park, and accessi-
ble to the large hospitals. Since the last announcement, the wards and
rooms of the hospital have been constantly occupied by patients, whose
cases have been made available for instruction, while the dispensary
has furnished ample material in ambulant patients. There are histo-
logical and pathological laboratories connected with the school, as well
as one for physiological investigations. During the year a large sum
of money has been given the hospital by a benevolent lady, through one
of the lecturers of the school, for the purpose of fitting up and sup-
porting a ward for the treatment of sick children. It is believed that
similar gifts will enable the faculty at no distant day to fully support
from endowment funds a large number of beds, so that a hospital suf-
ficient for all purposes of instruction, except in general surgery and
medicine, may be found within the walls of the school."
The Various Pharmacopoeias. — On the authority of Kobert, " Lyon
medical " gives the following statement as to the number of drugs rec-
ognized in the various pharmacopoeias :
French 2,000
Spanish and Belgian [? each] 1,500
Russian 1,080
Greek and Swiss [? each] 1,040
United States 1,010
British 815
Swedish 740
Danish - . . 720
Dutch 665
German 600
Austrian 560
Hungarian and Roumanian [? each] 545
Norwegian' 530
The Failure of the Vivisection Bill in Pennsylvania. — The " Medi-
cal and Surgical Reporter," of Philadelphia, says :
" The Pennsylvania branch of the American Society for the Restric-
tion of Vivisection has lately distributed several tracts and pamphlets
in pursuit of its aims, and to influence the public in favor of its efforts.
One of these is entitled ' Facts in regard to the failure of the bills pre-
sented to the Legislature for the restriction of vivisection.' The brunt
of this statement bears heavily on Drs. H. C. Wood and S. W. Mitchell.
They are accused of having promised the society to support a bill
which, before the legislative committee, they threw cold water upon.
" A careful reading of the ' statement of facts ' — and we have not
sought other sources of information — will easily explain the position
assumed by these gentlemen. Both of them, and for that matter all
physicians, are perfectly willing to support a bill restricting vivisection,
provided that, a sensible restriction being admitted, the matter will end
there, and no further agitation be begun to do away with it altogether.
This was the assurance Dr. Mitchell aske 1, and that the society did not
give. They say their committee was not prepared for the question.
We ask, Are they prepared now to give an affirmative reply ? We have
good reason to know they are not. We have excellent authority for
saying that the society intends to continue to agitate and appeal, with
the hope of abolishing vivisection entirely. This is evident from their
pamphlets, as well as their spoken utterances. Their name, 'For re-
stricting vivisection,' is merely a disguise for their real intentions, and
not an honest intimation of their final purpose.
"Such being the case, all must approve of the action of the gentle-
men named. They did not intend to commit themselves to the projects
of a society which declined to express its real designs, and merely
wanted to use them as stepping-stones to results which they con-
demned.
" While disapproving of causing unnecessary pain to any organic
creature, we acknowledge but little sympathy with the sentimental af-
fection for brutes now so prevalent. To a well-ordered mind, no sight
is less pleasing than to see a woman fondling and kissing some ugly
cur of high degree, when her own children are lacking in physical or
moral education, or when she is taking nightly precautions not to have
children — and this sight is no rare one in our civilization."
THERAPEUTICAL NOTES.
Sulphide of Carbon. — In a recent number of the " Progres medi-
cal " we find a resume of a graduating thesis on this substance, by M.
Sapelier. The writer insists on the importance of distinguishing be-
tween the commercial article and pure sulphide of carbon, the former
being contaminated with sulphide of hydrogen in varying proportions,
to the action of which the poisoning of workmen engaged in the manu-
facture is attributable. Sulphide of carbon is available in medicine as
a rapid and energetic revulsive, and, in solution, it is one of the best
of intestinal antiseptics, especially in typhoid fever. The same journal
gives the substance of a recent communication on the same subject,
made before the Academie de medecinc, by M. Dujardin-Beaumetz, who
gives the following formula for a solution for internal use (eau mlfo-
carbonee) :
Sulphide of carbon 375 grains;
Essence of mint 50 drops;
Water 16 ounces.
This is to be shaken and allowed to settle. From four to ten des-
sertspoonfuls of the solution may be given daily.
Nitro-glycerin in the Treatment of Interstitial Nephritis. — As
opposed to the theory that a sufficient urinary excretion is kept up by
the increased arterial pressure consequent upon the cardiac hypertro-
phy, Rossbach (" Berl. klin. Woch." ; "Union med.") adduces there-
suits which he produced with nitro-glycerin in three cases of contracted
kidney, in which the patients had increased arterial tension, albuminuric
retinitis, uraemic asthma, and the general ill-health characteristic of
generalized and advanced arterial sclerosis. In spite of the lowered
tension produced by the drug, the uraamic symptoms were diminished,
the urine was increased in amount, the albuminuria became less evi-
dent, and the retinitis grew less marked and less troublesome.
An Ointment for Intertrigo. — In a recent discussion at the Paris
Societe de therapeuiique, M. Campardon ("Progr. med.") stated that an
ointment made after the following formula had answered well in his
experience :
Borax 30 grain ;
Oil of wintergreen 10 drops;
Vaseline 74 drachms.
A Calmative for Teething Children. — M. Vigier (" Gaz. hebdom.
de med. et de chir.") gives the following formula of a sirop de denti-
tion :
Hydrochlorate of cocaine 1| grain :
Tincture of saffron 10 drops;
Syrup 2\ drachms.
The painful gums are to be gently rubbed with this syrup several
times a day.
THE KEW YORK MEDICAL
dDrirjwal Communirati0rt&.
RHACHITIS*
By HENRY N. READ, M. D.,
BROOKLYN.
Rhachitis, though a very common and important dis-
ease of childhood, has received, in this country at least,
much less attention than it merits. Since I have been a
member of this society I can not recall a discussion of or
paper upon this disease. Occasionally, in the pathological
societies of this city or New York specimens of this disease
are exhibited, but they are usually confined to the grosser
and later lesions of the disease. My object is, in this
communication, to call attention to the earlier manifesta-
tions of rhachitis — those manifestations which are not in-
frequently overlooked in the treatment of cases, but which,
unless recognized and treated, will often render nugatory
all remedial measures adopted. One can not but be struck
at the large number of fatal cases of the simple catarrhal
diseases when looking over the mortuary reports of these
two cities. In the cold months bronchitis and the warm
months diarrhoea appear with great frequency as the causes
of death in the statistics. These disorders, if simple and
occurring in healthy children, do not excite alarm, and
are very manageable. The mortality from them, therefore,
means something more than appears on the faces of the
death certificates; and, on examination, rhachitis will be
often found as the silent factor in the production of the
fatal result. A somewhat extended experience in the de-
partment of pa;diatrics, both as a practitioner and as phy-
sician to public institutions in this city, has established
the opinion in my mind that rhachitis is second only to
tuberculosis, and indeed not very far second to this disease
as a general or constitutional disorder of childhood — far
more so, I believe, than either struma, syphilis, or simple
atrophy. Rhachitis is never a congenital disorder, nor,
strictly speaking, even a diathetic disease, if by diathesis
we mean a constitutional predisposition to the development
of a certain affection. It is rather a developmental disorder
brought about by exterior surroundings, though, of course,
it may be developed in those children who have an inherited
tendency to other diseases. Its great frequency, its vicious
modification of unimportant maladies, and its injurious
tendency if not recognized and treated, render this affection,
therefore, of peculiar interest to the practitioner. Rhachitis
may be defined, then, as " a general disease," not hereditary
or diathetic, " affecting the nutrition of the whole body ;
arresting natural growth and development ; perverting and
delaying ossification ; retarding dentition ; causing the
bones to become soft and to yield to pressure, and the mus-
cles and ligaments to waste ; and in many cases producing
alteration of the brain, liver, spleen, and lymphatic glands."
To treat exhaustively of the aetiology and pathology of
rhachitis would require an article of greater length than can
* Read before the Medical Society of the County of Kings, June 16,
1885.
JOURNAL, August 29, 1885.
be condensed into the limits of one of several papers of an
evening, and I shall therefore briefly outline this portion of
my subject, as I wish to speak principally of the earlier
clinical symptoms of the disease — a recognition of which is
of great importance. Rhachitis is produced by one, or the
conjunction of several agencies. It is a direct consequence
of malnutrition, and its causes must therefore be sought
for in all the numerous agencies which injure the nutrition
of the developing child. The prime ones are those which
fall under the heads of improper food and defective hygiene.
Insufficient and especially unsuitable food, and want of fresh
air and sunlight, are the two causes to which rickets may be
charged. The first two, by starving the body, and the last
two, by rendering assimilation defective, produce, either
together or alone, that condition which we know as the
rhachitic condition. The majority of cases are found, of
course, among the poor, but the disease is by no means con-
fined to this class. A very considerable number of cases
occur in the ranks of those denominated " independent,"
and not infrequently does it occur among the very wealthy
and luxurious. Among the poor, if I should designate any
one cause which I consider more potent than another in the
production of rickets, I should undoubtedly indicate want of
sunlight. Among the rich, or those in comfortable circum-
stances, improper food takes the first place. When the
nursing child is weaned is the time usually for the com-
mencement of rhachitis. The mother's milk is replaced by
the starchy foods in such kind or quantity as to impair
assimilation, and the morbid process is set up. Rhachitis
may also be developed by too long a continuance of nurs-
ing, the mother's milk being, from age or impoverishment,
unsuitable to the growing wants of the system. Rhachitic
children from this cause may often be noticed where moth-
ers who have borne children rapidly continue to nurse the
youngest for a long time after the proper age for weaning
has arrived, to prevent a new pregnancy. The location of
the habitation, I have frequently noticed, produces a marked
effect on the development of rhachitis. The basements
of tenement-houses and the rooms on the northern side of
a house will produce more rhachitic children, other things
being equal, than rooms more favorably situated. The age
at which rhachitis is produced must be noticed. It is sel-
dom seen under one year of age, and almost never under six
months. The cases of so-called "congenital rhachitis" are
not true cases of the disease. Neither is there any connec-
tion between rhachitis and congenital syphilis, though Pa-
not has labored with no little ingenuity to show them to be
identical. The period of its inception, therefore, shows a
close connection with weaning, and naturally with the inges-
tion of unsuitable food. The tubercular diathesis, strange
to say, seems to%wield a protective influence against rhachi-
tis. This is probably explained by the fact that children
who are born tuberculous will, from the causes which develop
rhachitis — viz., bad air and food — die of tubercular phthisis
ere rhachitis can be set up. The pathology of rhachitis
must be passed over briefly. The first and chief pathologi-
cal change in this disease is the generation of lactic acid in
the deranged digestive organs of children. Heitzman as-
226
READ: RHACHITIS.
[N. Y. Med. Jolk.,
sorts that tliis acid excites irritation in the osteoplastic tis-
sue, and at the same time dissolves and helps to eliminate
the calcareous tissue already formed. If, in addition, the
food given the child be deficient in the lime salts, the rha-
chitic process, it is obvious, is hastened and made sure.
The brunt of the disease falls upon the bony structures,
though nearly all the tissues of the body are more or less
affected, and some of them early in the disease. The bones
are exceptionally rich in water, fat, and carbonic acid, but
deficient in the lime salts — the normal proportions of these
ingredients being reversed from 63 to 65 per cent, to 37 to
35 respectively, inverted, as it were, from the healthy stand-
ard. The bones become then of less specific gravity, and
are softer and more easily bent or broken. The epiphyseal
ends of bones are always enlarged, and the periosteum
thickened, inflamed, very vascular, and with difficulty de-
tached from the bony structure underneath. The micro-
scopical changes in the osseous tissues consist, according to
Kolliker, Virchow, and Muller, of a remarkable extension of
the spongy layer, an abundant proliferation of the cartilage
cells in the primary cartilage layer, in deficiency or complete
absence of calcification of the osseous and cartilaginous
substance, in disproportionate extension of the medullary
cavity, and delayed alteration of the cartilage tissue. The
formation of bone out of the cartilaginous tissue takes place
irregularly, and the zone of proliferation, as the vertical col-
umns of the corpuscular elements which are forming to re-
ceive the deposit of earthy salts are called, is not separated
from the zone of calcification — the layer which has already
received the deposit — by a well-marked line of demarkation
as in healthy bone. The two zones are greatly thickened
and ossification takes place irregularly, little spiculse and
islets of bone being found in the proliferating layer, and in-
complete ossification in the calcified layer. According to a
late observer, Strelzoff, the osseous trabecular, from this ir-
regularity of formation, have an abnormal arrangement, and
are disposed radially instead of concentrically. This ar-
rangement is supposed to be an additional cause of weak-
ness, therefore, in the bone, and to render it still less capa-
ble of resisting pressure or strain. The muscles in this
•disease are small, flabby, soft, and pale, the striaB being very
indistinct. The brain is small and shrunken, and fluid is
usually exuded to fill up the cavity of the skull, which is
generally enlarged. For the reasons before mentioned, the
pathology of the internal organs must be omitted, as well
as those very interesting morbid changes which take place
in rhachitis from mere mechanical causes, such as pulmonary
collapse and emphysema, hepatic engorgement and fatty
degeneration, etc. To speak briefly of the prognosis in
rhachitis, before passing on to the symptoms, it may be
stated to be good, provided the disease is recognized early.
In none of the constitutional diseases, except the congenital
syphilis of infants, do we get better results from proper
treatment than in rickets ; but to be managed successfully
it must be recognized in the early stages. It is rarely a
primary cause of death, but as a secondary cause it is sec-
ond to few of the diathetic diseases. Vast numbers of
deaths from bronchitis — simple and capillary — pulmonary
collapse, diarrhoea, laryngismus stridulus and other disor-
ders, are really due to rhachitis. The symptoms of rickets
can be readily recognized, but are often in my experience
overlooked or misinterpreted. The first symptoms are the
sweating about the head, the feverishncss at night, the
tendency to kick off the covers on the part of the child, the
indigestion, grinding of the teeth, diarrhoea alternating with
constipation, pasty, dull complexion, circles under the
eyes, and tumid belly. These cases are nearly always
treated for worms before the real trouble is suspected.
Next in order the child becomes fretful and cross, and cries
if moved or dandled, evidently suffering pain from hand-
ling. He sits quiet and makes no attempt to move; will
play with toys put into his hand, but makes no effort to go
after them. The digestive derangements at first are limited
to a lessening of the digestive powers; indeed, the symp-
toms pathognomonic of rickets are always preceded by those
general symptoms which indicate simply impaired nutrition.
Such have been mentioned. The stools are large, pasty in
consistence, offensive in odor, and contain large quanti-
ties of undigested materials, as well as slime and greenish
masses. Flatulence is common. The urine is very acid
and causes pain in voiding. The sweating, slight at first,
now becomes very profuse, and occurs principally during
sleep. Beads of moisture stand on the brow of the child,
and the pillow is usually wet in the morning. Following
this commence the changes in the bones characteristic of
the disease. The ends of the bones are enlarged and the
shafts thickened. All the joints are notably increased in
size, the wrists and ankles being peculiarly noticeable. Great
tenderness is manifested not only in the bones and joints,
but in the muscles also. The bones of the upper extremi-
ties are affected first, and first of these usually are the ribs.
The enlargement of the sternal ends of the ribs is one of
the most commonly recognized symptoms of rhachitis, and
gives to the chest the well-known beaded appearance, as it
is called. The whole thorax is altered later, the sternum
being carried forward, and the ribs are driven in laterally in
expiration, producing the deformity known as the "pigeon
breast." It is in the skull, however, that the most im-
portant bone changes take place — most important because
I believe that rhachitis may be recognized, or at least sus-
pected, before other symptoms have become marked, from
the appearance of the skull alone. The skull in the large
majority of rickety children is too large. The method of
obtaining the measurement of children's heads I published
some years ago in " The Pathologist." It is easily done
and is quite accurate, and, at the risk of repetition, I will
briefly describe the method here. The plan follows the
rules laid down by Dr. Samuel Gee, of London, in an article
on the " Shape of the Head looked at in a Medical Point
of View," published in the "St. Bartholomew's Hospital
Reports for the Year 1871." Dr. Gee states the rule to be
that " in the head of the healthy child the ratio between
the greatest antero-posterior diameter of the cranium and the
base-line is as six to five." In other words, the cranium is
about one fifth larger than its base. This, rule I have tested
for some years, and have measured many hundred heads
according to it. I have found it remarkably accurate. Two
principal varieties of large heads are met with in children —
August 29, 1885.J
READ: BHACniTlS.
227
the ct/clocephala?, or round heads, aud the dolichocephala, or
long heads. The first, or cyclocephalic head, almost always
belongs to the tubercular child, and the second, or dolicho-
cephalic head, almost as invariably belongs to the rhachitic
child. This fact, it will be readily seen, is of great use. A
child with a dolichocephalic head may, prima facie, be sus-
pected of rickets ; if, in addition, there be delayed denti-
tion, there are ten chances to one that rhachitis is present.
In examining the heads of children it is important to re-
member two things: first, that shape, not size, of the head
is of most value ; second, that long heads mean increase of
the solid contents of the skull, and that round heads mean
increase of the liquid contents of the skull. To ascertain
the base-line and greatest antero-posterior diameters of the
cranium, only a pair of calipers and a tape-line are neces-
sary. The procedure is as follows : One leg of the calipers
is placed upon the glabella, the other just beneath the tuber
occipitale ; the calipers is then removed carefully without
displacing the legs, and the distance between the two points
of the instrument is carefully noted. This is roughly the base-
line of the skull. One leg of the instrument is now placed
on the most prominent portion of the frontal bone, and the
other leg upon the most prominent part of the occiput ; the
calipers then being removed, the distance between the two
points will give us the greatest antero-posterior length of
the skull. These two measurements must be in the propor-
tion of five to six to each other ; a very simple sum in pro-
portion will, therefore, enable us to tell whether the head is
abnormal or not. The following case may serve as an in-
stance : C. L., a large, fat, dull-looking child, was placed in
the Sheltering Arms Nursery. She was twenty-two months
old, and had been nursed till her admission. Had delayed
dentition, and some digestive disorder, not very great.
Seemed in good health. Head measurements gave base-line
4-| inches, and greatest length of cranium inches. Ap-
plying the rule given, we find that in the normal head we
have 5 : 6 : : 4| (base of patient) : 5^. Therefore the child's
greatest length of skull should have been 5^ inches, where-
as it was 6£ — an inch larger than normal. She was pro-
nounced rhachitic, and placed on appropriate treatment
She got along well* till about a month after admission, when
she died of capillary bronchitis after less than twenty-four
hours' sickness. The autopsy showed rhachitis existing, but
apparently improving.
The symptom of craniotabes, described first by Elsas-
ser, is found in a certain number of cases. It is, however,
rare in my experience, though it seems to be frequent in
Europe. It is a lesion of the bones of the skull, generally
the occiput, and is detected by pressing with the tips of the
fingers firmly on the head. If the condition be present, the
bones yield slightly under the finger-tips, a small indenta-
tion being made. The spots where this change of bone
takes place are small, and are due to imperfect ossification.
The symptom may be met with as early as the sixth month,
according to some authorities.
The last symptom which I shall notice is the delayed
dentition. In a large majority of cases the evolution of
the teeth is retarded till the tenth, twelfth, or fifteenth
month, and after the teeth are cut they quickly blacken and
crumble away. This symptom, however, unless accom-
panied by others, is of no great value, as delayed dentition
depends on many other causes than rhachitis. The length
to which this article has already extended itself will pre-
vent me from dwelling on the treatment of rhachitis in de-
tail. I shall, therefore, only outline briefly the management
of this disease which I have found most successful. The
treatment may be divided into the hygienic and the medi-
cal. Under the first head comes the supervision of the
child's whole life. If the patient be at the breast, it should
be immediately weaned if possible. The food should be
personally inspected, both as to quality, quantity, and times
of administration, no hearsay evidence being admitted; nor
should the attendant confine himself to the giving of direc-
tions alone, but should see that they are properly carried
out. If the starchy foods are given in excess, this should
be corrected; if the variety of starch given be one diffi-
cult of digestion, another should be substituted for it, or a
small quantity of malt added to the food, as is done in the
Mellin's food. Finely chopped beef, fresh eggs, and pep-
tonized milk should be added in suitable quantities to the
child's diet. Saccharine matters should, as a rule, be avoided,
as large quantities of sugar encourage fermentation and
acidity and provoke diarrhoea, to which the patient is
already too liable. Mutton-, chicken-, or clam-broth, with
stale bread and fresh butter, may be allowed. The alvine
discharges should be carefully inspected, and diarrhoea cor-
rected by a small quantity of the bicarbonate of soda, ad-
ministered in peppermint-water with a few drops of spirits
of chloroform. This will also relieve the flatulency which
is apt to occur. The clothing of the patient should receive
the utmost care. Flannel should be worn next the skin
winter and summer; in the latter a broad flannel bandage
over the bowels is usually sufficient. The child should be
bathed twice a day, and the body rubbed well with cod-
liver or olive oil. The profuse perspiration may be checked
by applying the tincture of belladonna — a teaspoonful to
half a pint of water — several times daily to the skin. The
patient must be taken into the open air regularly twice
daily, no matter what the season is, provided it does not
storm. It is far better, in my opinion, to take the chances
of the child's taking cold than of his staying in-doors ; very
young or weakly children in cold weather can be wrapped
up warmly and a bottle of hot water or a hot brick can be
placed in the carriage with them, and they can be trundled
about for an hour or so with safety on the score of getting
cold. In the case of those who live in basements or north-
ernly exposed rooms a change of residence is desirable.
After indigestion has been corrected and the stomach got-
ten into good condition we may commence the exhibition
of therapeutical agents. Cod-liver oil and the ferruginous
tonics are the chief remedies to be employed. It is well to
begin with a small dose of the oil, fifteen to twenty minims,
as the power of digesting the fats is small in rickety chil-
dren. This can be gradually increased. Iron, quinine, and
the bitter tonics may be employed afterward as occasion
demands.
228
HEAL)
ECLAMPSIA IN EARLY LIFE.
[N. Y. Med. Jour.,
ECLAMPSIA IN EARLY LIFE*
By JOSEPH HEALY, M. I).,
BROOKLYN.
Diseases of children present peculiar difficulties to one
■who has studied the phenomena of disease in the adult.
This arises from the fact that in the nervous system of the
child the spinal predominates over the cerebral ; and this
is as it should be, since the different organs of the animal
economy necessary to furnish nutrition for bodily growth
and development are in active progress long before the in-
fant formulates ideas, or really interprets fully the sounds
that reach the ear, or the visions upon the retina.
The intense excitability of the nervous system in the
healthy and robust child which gives to a trivial ailment
symptoms of a grave disorder under the influence of en-
feebling and chronic diseases, becomes diminished and dis-
appears, so that we find a condition exactly opposite.
Now, the nervous system has become insensible to the irri-
tations of local ailments, and we search in vain for general
manifestations. Ofttimes the local symptoms are so slight
and obscure that they may easily escape our notice.
But, although a mere functional derangement may for a
time excite such a tumult of disturbance in the general sys-
tem as does a severe organic lesion, we must treat these
general manifestations with a very careful appreciation of
the susceptibility of the little organism to the shock.
And, on the other hand, we must consider the vital im-
port of sufficient strength being furnished from without to
the enfeebled one, who can not bespeak to the professional
eye the expected manifestations of diseased action. Hence
it behooves every person, who hopes to successfully treat the
little ones in their many and varied ailments, to be cogni-
zant of the dissimilarity of diseased action in the adult to
the ever-changing and often contradictory phenomena of
disease in children.
Let us consider for a few moments, and in a not far-
extended or minute detail, one of the most common and
often the most appalling morbid conditions in early life.
I refer to eclampsia, or general convulsions.
The term "convulsions" is applied to different forms of
spasmodic disease in which muscular innervation is de-
ranged or perverted so that the movements become irregu-
lar and automatic and are no longer controlled by the will.
We may make several classifications of convulsions, ac-
cording to our estimation regarding their nature or cause.
Many of the French writers make three classes — idiopathic,
sympathetic, and symptomatic.
The first two are not accompanied by any appreciable
lesion of the nervous system, while in the third the convul-
sions indicate a sign or symptom of some disease of the
nervous centers, as meningitis, tubercular disease, hydro-
cephalus, etc.
With all due respect for the French school, a classifica-
tion into two varieties seems more reasonable and appro-
priate— namely, congestive and amende. Whatever the ex-
* Read before the Medical Society of the County of Kings, June 16,
citing cause, all convulsions may be classed under these two
heads, and demand, if congestive, one line of treatment; if
anaemic, another.
The susceptibility of the sympathetic and spinal nerves
of early life to impressions and irritations of trivial charac-
ter produce in a child of nervous temperament an ever-
changing series of convulsions whenever the health becomes
even slightly impaired ; this susceptibility, as the brain be-
comes more and more developed and endowed with the
control of later years, is gradually diminished and blunted,
so that, as the years of infancy are passed, the effervescent
display of nervous irritation fades into more stable manifes-
tations of diagnostic value.
Even in the adult, when diseases producing hypersesthe-
sia of the spinal cord are present, all the varied reflex
movements peculiar to the convulsed child appear.
In general, we may say that convulsions rarely prove
fatal, yet every one who has practiced medicine has been
summoned to his first case of a " baby in a fit." Perhaps
his summons has filled him with apprehensions lest it prove
his first certificate to sign, and render him open to criticism
from the all-knowing neighbors in female attire. Should
there be any before me who have not yet been summoned,
let me say to him, Fear not, but go, and that, too, as quickly
as possible; for, ten chances to one you will find the child
first-rate, and hemmed in by. ten or a dozen seemingly anx-
ious individuals crowded around the poor unfortunate, ab-
sorbing all the oxygen the narrow bedroom may contain.
If the convulsions have passed, even now you must do
something and impress the bystanders with the importance
of your presence. Give every one something to do and
an opportunity to show their kindly interest and sympathy,
while you see that everything is done to prevent a recur-
rence of the fit.
Should you find the child in the midst of the attack,
act promptly and thoroughly ; do nothing blindly, nor order
any shot-gun dose to cover every possible cause of the dis-
turbance.
First allay the spasm. Generally the relaxing properties
of a hot mustard-bath will prove sufficient, with some pun-
gent application to the nose, or the administration of the
bromides, chloral or asafoetida, by the mouth or by enema.
But, should the convulsions still continue and be severe, I
invariably resort to the inhalation of chloroform and alcohol
until the spasm be controlled and inquiries made in search of
the cause, when the appropriate treatment may be chosen.
Many suggestions have been made as to the proper
mode of treating severe spasms, each of which is claimed to
be the one to follow. The above has proved adequate in
my practice, but I can not but mention the hypodermic in-
jection of chloral and the inhalation of nitrite of amyl with
injections of morphia, in hopes that some one before me
may have had experience with these agents that may prove
of benefit for us to know.
There is no position in which a newly fledged M. D.
may be placed, if he be possessed of a clear intellect and
well informed and thoroughly disciplined in professional
truths, where he may show the staying qualities of his judg-
ment and tact as here, for the eyes of the neighborhood
August 29, 1885.] NORTHRIDQE : SALICYLIC ACID IN INTESTINAL CATARRH.
229
are upon him, and the verdict to be rendered will mean for
him patronage or abuse.
First have confidence in your own ability, then you may
inspire confidence in others. But the child still struggles.
Let a hot bath be ordered, the room thoroughly ventilated,
the pulse examined (if full and bounding, it will suggest
congestion ; while, if weak and feeble, anaemia or syncope),
make inquiries concerning the attack, if this be the first, if
the child has eaten anything unusual, if exposed to any
malady, what acute specific diseases have been passed. Ex-
amine the head, whether cool or hot, the fontanelle protrud-
ing or retracted, the eyes congested or natural, the face
flushed or pale, the gums red and swollen. Then strip the
youngster and see if the legs are drawn up on the belly,
the extremities cold or hot, the respiration deep or shallow,
the belly tumid or lax.
By observing these different conditions, the line of treat-
ment may be mapped out.
A pulse of 130, with accompanying headache, vomiting,
and fever would indicate a digestive disturbance, and, if
seen early, an emetic of ipecac, followed by a calomel pur-
gative, will be of service, and later bismuth and soda. A
slow and feeble pulse of 40 would suggest the advent of
meningitis, where the bromides are of signal value.
If there has been diarrhoea, and the head cool, pulse
weak, then a little brandy and water may be given ; and even
if the child be emaciated from disease, and the head be hot,
the pulse rapid but small, we may still rely on brandy.
In some cases we find flatus in the bowels producing
convulsions and the belly tumid; here friction with hot
mustard-water, together with some carminative, as pepper-
mint, anise, etc., should be given, rubbed up with sugar,
and placed well back in the mouth.
As a rule, convulsions at the commencement of fevers
do not indicate a grave prognosis, whereas if they occur
later in its course they almost always suggest serious appre-
hensions.
In pertussis and diseases depending on a vitiated condi-
tion of the blood, where the convulsions follow closely one
upon the other, our prognosis should be guarded.
When the fits are of short duration and moderate in
intensity, with a natural, cheerful countenance soon return-
ing, everything may be considered satisfactory ; but if long-
continued and occurring closely together, with a dull, heavy,
anxious expression remaining, the danger is imminent.
Quite often much may be done when the attack is over
to prevent a recurrence by avoiding the known causes, and
by the soothing effects of the warm baths and bromides in
children predisposed to this affliction.
But, notwithstanding the rapid strides in medicine, we
may still have prodromata or none ; the convulsions may be
long or short, slight or severe, partial or general, recurring
constantly or at long intervals, all of which points will- re-
quire careful attention in each individual case, and tax our
best endeavors to obviate, until we attain such perfect
health that " there shall be no more an infant of days, nor
an old man who hath not filled his days," but a blissful
euthanasia await us all.
77 Gates Avenue, Brooklyn.
THE SALICYLIC-ACID TREATMENT
OF THE
INTESTINAL CATARRH OF INFANCY*
By WILLIAM A. NORTHRIDGE, M. D.,
BROOKLYN.
During the summers of 1882, 1883, and 1884, while
physician resident at the Seaside Home for Children, Coney
Island, I became greatly impressed with the value of sali-
cylic acid in the treatment of the inflammations of the in-
testinal canal, so common among young children during
"the heated term." I venture this paper with the hope
that it will lead many of you to give this remedy a fair trial
in this class of diseases. The time is most opportune, as
these maladies are now appearing among the little ones ;
are even now commencing their annual ravages. No effort
should be spared to check them, more fatal, as they are,
than any one of the contagious diseases so much feared.
The importance of the successful treatment of these diseases
is brought clearly before us when we examine the vital sta-
tistics of any large city and note the large increase of
deaths among young children from them during the third
quarter of the year. The death-rate in this city for one
week of July, 1882, was over 52 per 1,000. Of the 603
deaths for the week, 262, or over two fifths, were from diar-
rhoeal diseases among children under five years of age.
Whether the diarrhoea be due to teething, improper food,
action of heat on the sympathetic nervous system, or to any
or a combination of conditions as exciting causes, there
seems to be very little doubt but that the proximate cause
is a pathological condition, probably due to microscopic
organisms. I will not go further into the aetiology of these
diseases, but will at once state that in salicylic acid we have
a remedy of great value in their treatment ; of course aided
by proper nursing, dieting, and hygienic surroundings, with-
out which medication would be valueless. I do not wish
to detract from the value of opium in these diseases, cau-
tiously and properly administered ; but I do wish to protest
against the careless routine use of the drug, because of its
tendency to aggravate the passive congestion of the brain
and the serous effusion into its membranes, which so often
occurs and is so fatal. Salicylic acid is absolutely harmless
and safe ; children bear it very well. It may be adminis-
tered to a weak infant in comparatively large doses, say one
grain and a half every two hours, without danger. The
formula used at the Sanitarium is in the following propor-
tions :
R Acidi salicylici gr. iij ;
Cretae preparatae gr. ij ;
Syrupi simplicis 3 j- M.
This much at a dose to a child of six months or over
every two hours. As with other remedial agents, the medi-
cine must be supplemented by proper diet, nursing, and,
above all, by removal from the disease-breeding atmosphere
of the city to the pure, fresh air of hills or sea-side whenever
possible. The patient will begin to improve after the ad-
* Read before the Medical Society of the County of Kings, June 16,
1886.
230
NORTHRIDQE: SALICYLIC ACID IN INTESTINAL CATARRH. [N. Y. Meu. Johk^
ministration of a few doses, and in twenty-four hours the
case generally will be markedly better. It will be noticed
that the passages diminish in frequency, the watery,
greenish-yellow stools being replaced by those commencing
to have consistency and to assume a more natural color. In
severe cases the passages become gradually less frequent.
There is rarely a sudden cessation of the diarrhoea. From
ten or a dozen movements on the day of beginning treat-
ment, a reduction will be observed on the next day to five
or six, with improvement in character. On the following
day a further improvement, and so on until one natural pas-
sage is obtained. The following cases are from my case-
book, and were kept separately from the regular books of
the Home. They occurred among children sent to the
Home during the summer of 1884. No choice was ob-
served save that the very sick were chosen on their arrival
at the Island.
Case I. — June 18th, Edward M., aged six months, sick two
weeks. Three large, green passages to-day, containing undi-
gested food and mucus. Child artificially fed; no vomiting;
no fever; pulse weak. General condition poor. Ordered diet
of boiled milk, lime-water, and arrow-root. Small doses of
brandy as stimulant, and mist, salicylic, in 3 ss. doses, every two
hours. 19th, child passed good night, is brighter; diarrhoea is
less in quantity but continuing. 21st, considerable pain during
night; diarrhoea still. 23d, six passages during day, less pain.
25th, baby much better ; only one natural movement. 27th, he
is much improved ; has had no passage since 25th ; sleeps
well, no pain. 28th, passed good night; had one natural move-
ment ; no pain ; baby brighter. Medicine withdrawn.
Case II. — July 14th, Edward C, aged seventeen months.
Sick seven weeks. Three thin yellow passages to-day ; no vomit-
ing; great pain and restlessness at night; breast-fed. Gave
mist, salicylic, 3 j doses, every two hours, and also three grains
each of chloral hydrate and potassium bromide, with three
min. of the compound tincture of ipecac in mixture at night, to
relieve pain and restlessness. 15th, mother reports only one
passage since yesterday ; baby brighter ; slept well. 1 7th, baby
had perfectly natural passage ; goes home well.
Case III. — July 15th, Robert B., aged eleven months; sick
three weeks. Mother says daily average is twelve passages,
greenish-yellow and watery in character. No fever. Pulse
weak ; no vomiting; considerable depression. Child breast-fed.
Ordered mist, salicylic, 3j, every two hours, and child to
pavilion. 16th, five passages to-day ; child brighter. 17th, one
passage. 18th, one movement, natural; no vomiting; sleeps
well ; medicine withdrawn.
Case IV. — July 21st, J. T., aged nine months; sick two
weeks; child teething; vomiting and diarrhoea; fifteen passages
to-day ; only little at a time, watery and green ; fever and pain
at night; pulse weak and rapid. Treatment: Gave two minims
aromatic ammonia spts. every half-hour as stimulant; quieting
mixture at night, and mist, salicylic, in 3j doses, every two
hours. 22d, 8 a. m., passed a poor night, vomiting and diar-
rhoea still continuing. Ordered treatment to be persevered in,
and gave drop-doses of the wine of ipecac every hour, which
efficiently controlled the vomiting ; 5 p. m., same day, diar-
rhoea checked. 23d, baby had natural passage; no vomiting;
discharged.
Case V. — July 28th, Jane M., aged five years and a half; sick
four days ; discharges dysenteric in character, containing blood
and mucus; straining at stool. Gave patient a mixture contain-
ng in each drachm oleum ricini, tii,xv; tr. ipecac, co., Bty;
vinum ipecac, fllij; glycerin, nix; mucilage acacia, q. 8. 3j.
Ordered diet of boiled milk and lime-water, crackers and rice.
29th, no improvement. 30th, none; changed the medicine, giv-
ing mist, salicylic, 3 j, every two hours. Improvement marked
from soon after the taking of first dose. 31st, child had natu-
ral movement. In this case the inflammation was carried fur-
ther than is usual.
Case VI. — July 29th, Fred. K., aged four years; sick one
day. Has had several watery passages; no vomiting; child
sleeps well. Gave mist, salicylic, in 3 j doses every two hours,
and put child on diet of boiled milk and crackers. July 30th,.
twenty-four hours after commencing treatment, mother re-
ported child well, and that he had bad one natural movement.
Case VII. — July 30th, James C, aged sixteen months; sick
four days. Several passages daily; watery, but no green color;:
vomiting; no fever ; sleeps well. Ordered mist, salicylic, 3jr
every three hours, and diet of boiled milk and lime-water. July
31st, not so many movements; much brighter. August 1st, one
natural passage ; general health much improved. August 2d,
discharged cured.
Case VIII. — August, 1884, M. O., aged two years and a half.
Mother wrote me from country that child was having from five
to nine greenish-yellow passages daily and losing flesh, when
she had filled a prescription I had given her, at her request^
before she left the city. This was mist, salicylic. She con-
tinued that, after a few doses of the medicine, the child com-
menced to improve and made a rapid recovery.
I might multiply cases from the books of the Home
which, through the kindness of my friend Dr. Walker, are
at my disposal, but I will refrain. Those which I have
read are typical of the action and curative powers of the
drug. Of the eight cases reported, all made a good recov-
ery. The average duration of the disease from the giving
of the first dose was two days and three quarters. Im-
provement was marked after the administration of the first
few doses in all save Case I ; and even in this case the diar-
rhoea was lessened and ultimately cured. The gradual ces-
sation allows time for the clearing out of any of the products
of inflammation or fermentation and the installation of
healthy intestinal action.
Its principal modes of action are two :
1. By its anti-fermentative powers.
2. By the alterative medicinal quality inherent in sali-
cylic acid, the salicylates and salicin in common.
1. By its anti-fermentative powers. Kolbe, Sternberg,
and others have clearly proved that in salicylic acid we
have an anti-putrefactive and anti-fermentative fully equal
to carbolic acid. Dr. Sternberg says : " A two-to-four-per-
cent, solution of salicylic acid will destroy the vitality of
germs, while the presence of a one-quarter-to-one-half-per-
cent, solution will prevent their development." Although it
has not yet been proved, it seems highly probable that the
pathological cause of these inflammations occurring during
the summer months is a microscopic organism, which, upon
the addition of heat, moisture, and improper food, enters
into an active fermentative process. Salicylic acid destroys
or inhibits this vegetable organism, upon which the activity
of the process depends.
But, says some one, The formula which you have read to
us, is there salicylic acid" there or a salt? I answer, A salt
for the most part ; but many particles of free acid are scat-
August 29, 1885.]
JEWETT: CESAREAN SECTION.
231
tered through the mixture. Tested with litmus-paper, it
proves neutral, save that the blue litmus is dotted red by
particles of free acid. On evaporating and rubbing dry
residue on litmus-paper and then wetting the paper, gives
an acid reaction. It is the amount of free acid in the mix-
ture which accomplishes the checking of the fermentative
process. This it does by its presence at the seat of disease
without entering the circulation.
Dr. M. Wagner writes of salicylic acid that " its use is
highly promising as a prophylactic in all diseases in which
it is believed that the morbid processes are connected with
microscopic organisms." He commends its administration
in all cases where fermentative changes occur in the aliment-
ary canal, because it may be administered in large doses.
Dr. Sternberg writes : " Dr. Keating, of Philadelphia,
strongly recommends salicylic acid in the treatment of the
acid diarrhoeas of children. In this case there can be little
doubt that the benefit derived from its use is to be ascribed
to its destroying or restraining the vital activity of the liv-
ing ferment to which the acid fermentation is due."
Its second mode of action is through the blood. We
know empirically that in salicylic acid, its salts, and in sali-
cin, we possess medicines which show the containing of an
inherent, valuable medicinal quality which we all recog-
nize. We know that they have an alterative effect upon
mucous surfaces, and in this fact probably lies an explanation
in part of their valuable medicinal action in these diseases.
While the healthy bowel is enabled to withstand the pres-
ence of a combination of disease-breeding elements, its pow-
ers of resistance being at par in consequence of good nerve
action and muscular tone, the deterioration of these by the
action of heat on the nervous system, the local action of
heat, and the imbibition of improper food, reduce this dis-
ease-resisting power until out of lowered healthy action
come diseased conditions. Further than this we can not
go in explanation, for we are in ignorance of the exact
mode of action ; but the fact of its curative powers is
known, and that is the main point. Dr. S. W. Smith, in the
"British Medical Journal " for 1884, vol. ii, says: " Willow
charcoal (salicin) is of great value in the treatment of diar-
rhoeas." He got the idea from Liverpool sea captains, who
use it. "Eminent medical men" whom he consulted
thought "that it was of great value in fermentative diar-
rhoeas."
Lawson (Heuseman, note, page 773, supra) advises
"the use of salicin in six-to-eight-grain doses, thrice daily,
in cases of summer diarrhoea resulting from direct action of
heat on the nervous system."
Dr. J. B. Mattison, in the "Medical and Surgical Re-
porter," 1873, advises the use of salicin in cases of diarrhoea
resisting other modes of treatment. In all cases where
salicin is used, the curative effect is due to its second or
alterative medicinal action, and not to any germicidal
effect. And now, in conclusion, I will state :
1. That in salicylic acid and its derivatives we have
most valuable remedies in the treatment of diarrhoeas, and
especially in those occurring among children during " the
heated term."
2. That its remedial powers are due, first, to the anti-
fermentative powers of the acid acting locally ; second, to
an alterative effect through the circulation.
3. That it is an efficient substitute for opium in those
cases where that drug is contra-indicated.
A CASE OF CESAREAN SECTION*
By CHARLES JEWETT, M. D., Brooklyn,
PROFESSOR OF OBSTETRICS IN THE LONG ISLAND COLLEGE HOSPITAL.
The subject of this report was a woman of about forty-six
years, of Irish birth, the mother of ten children — the youngest
four years of age, the eldest seventeen. She presented herself
in the out-door department of the Long Island College Hospi-
tal, at the clinic of Dr. Ernest Palmer, in August, 1883. Dr.
Palmer made the diagnosis of pregnancy, with cancer of the
cervix. At the seventh month of gestation she entered St.
Mary's Hospital, service of Dr. John Byrne. Dr. Byrne pro-
posed amputation of the cervix with the galvano-caustic loop,
but the patient declined the operation and left the hospital.
December 9, 1883, was admitted to the lying-in department of
the Long Island College Hospital. At this time she was weak
and ansemic from frequently recurring hemorrhages, complained
of constant pelvic pain, and slept little or none except by the
aid of opium. During the waiting period her temperature did
not exceed 99° F. The pulse ranged from 94 to 108. The
malignant growth now involved the supra-vaginal portion of
the cervix, and had commenced to invade the vagina.
Labor-pains began at 11 a. m., December 26th. At 8 p.m.,
though the pains had become severe, the cervix remained hard
and unyielding, barely admitting the finger. The membranes
were still intact. Delivery by the natural passages was evi-
dently out of the question. The hospital staff concurring, it was
therefore determined to deliver by Cesarean section. This
operation was accordingly done in the presence of the hospital
staff and a number of students, Dr. Skene, Dr. Palmer, and Dr.
Thallon assisting. The patient had been removed from the ma-
ternity to a large, well-ventilated ward, previously disinfected.
The abdominal surface in the field of operation was siiaved,
cleansed with soap and water, and then sponged with ether and
with the bichloride solution. When the patient had been placed
under ether, the abdominal incision was made through the linea
alba, from the umbilicus to a point about two inches above the
pubes. A loop of stout rubber tubing was then passed over
the uterus, and slipped down behind it till it encircled the cervix.
This constrictor was drawn taut enough to control the blood sup-
ply, tied in a single knot, and the knot held with a large Pcan
forceps. The uterus was drawn up into the abdominal wound by
traction upon the constricting tube. A very short incision was
made in the uterine wall just above the cervix. A tew light
touches of the knife uncovered the membranes, the muscular
tissues retracting from the line of incision. A blunt-pointed
bistoury was plunged through the membranes, and the incision
rapidly extended upward to a point short of the fundus. The
foetal head was immediately seized with both hands, and the
child, a living male of seven pounds and a half, extracted. The
uterus instantly contracted, partially expelling the phicenta
through the wound, and at the same time it was tilted out
through the abdominal incision by traction on the constrict-
ing tube. The membranes were now carefully detached. The
uterine cavity was cleansed and well mopped with aspongo wet
with the bichloride solution, and a pencil of iodoform was de-
posited therein. A utero-vaginal drainage tube, of half-inch
perforated rubber tubing, was passed down through the cervix,
* Read before the Brooklyn Pathological Society, February 26,
1885.
232
JEWETT: CESAREAN SECTION.
[N. Y. Med. Jock.,
terminating below at the vulva and above near tlie fundus.
The uterine wound was closed with deep and superficial sutures
of sublimated silk. The deep sutures included the entire thick-
ness of the uterine wall, except the decidua. The superficial
sutures were passed as follows : A fold of peritonaeum was lifted
near the edge of the uterine incision, and parallel with it. The
sutures were passed transversely through this fold, and through
a similar fold on the opposite side of the wound, thus twice per-
forating the peritonaeum on either side of the incision. On
tying the sutures, therefore, two free surfaces of peritonaeum
were brought in contact. The uterus, which had been drawn up
through the abdominal incision on extraction of the foetus, was
now dropped back into the abdominal cavity. But slight ooz-
ing of blood occurred into the vagina on removing the con-
stricting tube. The peritonaeum was cleansed with hot aseptic
sponges, a drachm or two only of fluid being obtained. The
abdominal wound was closed with sublimated silk sutures. A
long, curved glass drainage-tube was passed down beside the
uterus into Douglas's pouch, emerging between the sutures of
the abdominal wound. A dressing of sublimated cotton was
applied over the abdomen, and marine lint to the vulva. The
mouth of the abdominal tube was closed with an antiseptic
sponge and rubber tissue in the usual manner. A partial anti-
sepsis was observed throughout, a five-per-cent. solution of car-
bolic acid being used for instruments and a l-to-1,000 bichloride
solution for other purposes. The uterus, while turned out ot
the abdomen, was enveloped with towels wrung out of hot dis-
infectant solution, frequently changed, and the upper portion
of the abdominal incision was protected with similar covering
to prevent prolapse of intestines. The patient was removed
from the table with a pulse of 120. An hour later, pulse
110, temperature 99°. There was little or no vomiting after
the anaesthetic. During the first twenty-four hours the pa-
tient was comfortable, with the aid of occasional small doses
of morphia, upon which she had already become dependent, and
recovery seemed probable. At the end of that time the ab-
dominal tube showed accumulation of fluid in the peritoneal
cavity, at first clear and subsequently turbid, and the tempera-
ture rose to 102"6°. Death followed in forty-five hours after
the operation.
A complete autopsy could not be had. The abdominal
wound, which had united throughout, except at the seat of the
drainage-tube, was reopened, and the uterus and appendages re-
moved. The peritonaeum was everywhere injected and flecked
with fibrin — diffuse peritonitis. The cavity contained a small
accumulation of turbid serum. The uterine incision had united
throughout from the decidual to the peritoneal surface. Its
muscular structure, but for the malignant growth, was appar-
ently normal. The cavity contained a firm blood-clot, perfectly
sweet, and still yielding the odor of iodoform. The peritonitis
was thought to be due to an outbreak of erysipelas which had
occurred in the general hospital service a few days before the
operation, and which had also infected a maternity patient de-
livered on the same day with the Caesarean case. The uterus
as presented, after lying several months in alcohol, measures in
length seven inches on its posterior and seven inches and a half
on its anterior surface externally, and in width four inches at
the level of the Fallopian tubes. The anterior wall shows the
line of incision three inches and a half in length, and securely
closed throughout. The direction of the incision is slightly
oblique, indicating a slight right obliquity of the uterus at the
moment of incision. Twenty deep and superficial sutures can
be counted, though there are probably others that have escaped
detection.
Remarks. — The statistics of the Caesarean operation in
this country, thanks to the researches of Dr. R. P. Harris,
are well-nigh or quite complete. The case now reported,
writes Dr. Harris, "is the one hundred and thirty-fourth in
the United States. It is the seventh hospital operation,
and is the only case of Caesarean section in this country for
cancer of the cervix.
" Of the one hundred and thirty-four women, fifty-three
were saved. All the hospital operations were fatal.
" Of seven Caesarean operations in the United States since
April 6, 1884, all were fatal to the mothers, and all but the
above case fatal to the children.
" There have been thirty-three operations in the last dec-
ade, and twenty-five of them fatal ; four of the latter in
New York State. Thus the percentage saved has greatly
fallen off by the work of ten years, when it should have in-
creased. The great fatality was due mainly to delav, the
women being worn out with labor before the operation.
" We now number in North America, the United States
included, one hundred and forty-three operations, with sixty
women saved.
" In Great Britain, up to May, 1879, there had been one
hundred and thirty-two Caesarean cases, of which twenty-
three were saved and one hundred and nine lost.
" Seventy-seven children were saved and fifty-five lost.
In twelve of the above cases the operation was done owing
to cancer of the cervix. In this number four women and
ten children were saved. Thus it will be seen that in Eng-
land operations for cancer have been much more successful
than for any other form of obstruction."
The general record of Caesarean section, however, does
great injustice to its capabilities. Dr. Lusk has shown that
the mortality of the Caesarean operation has been due in a
great part to untimely interference and to other causes not
inherent in the operation itself. In cases operated early,
the statistics of Dufeilhay, cited by Dr. Lusk, show eighty-
one per cent, of women saved. In another series of sixty-
one operations in rural districts there were more than seventy-
eight per cent, of recoveries.
But even the best results thus far obtained are, with
very few exceptions, those of the unimproved operation.
The recent improvements in the technical methods of oper-
ating give promise of still better results. A prominent
cause of death after Caesarean section has been the tendency
of the uterine wound to gape, thus permitting the escape of
lochia into the peritoneal cavity. Various plans of treating
the uterine incision have been proposed with a view to ob-
viate this danger. Among them may be mentioned the
methods of Sanger, Kehrer, Pillore, Frank, and Cohnstein,
which, with others, will be found fully discussed in a recent
paper by Dr. Garrigues.*
The plan pursued in the foregoing case has the advan-
tage of simplicity, and is doubtless no less effectual than the
more elaborate method of Sanger.
The constrictor relieves the operation of a formidable
complication and adds to the chances of success, for,
while haemorrhage is rarely of itself alone the cause of
death, it contributes to the fatal issue.
The large proportion of successes in rural districts
* " Amer. Jour. Obstet.," April, 1883, et seq.
August 20, 1885.1
MOSUER: PULMONARY GANGRENE.
233
shows what is possible for antiseptics. Yet it is doubtful if
any thoroughness of antiseptic detail can justify operating
in a hospital. '
Germany is already beginning to reap the fruits of the
improved technique, Leopold, of Dresden, having saved
three women with their children by the Sanger method.*
In timely operation with the precautions now thrown
ahout ovariotomy, Cesarean section should not fall much
behind the record of other laparotomies.
PULMONARY GANGRENE.f
By ELIZA M. MOSHER, M. D.,
BROOKLYN.
Mary J. S., committed to the Massachusetts Reformatory
Prison for Women for drunkenness, May 6, 1879; age, twenty-
six years; single; occupation, general housework; was healthy
as a child ; became intemperate at eighteen, and acquired syphi-
lis. Had been sentenced many times to the Boston House of
Industry tor drunkenness.
When examined, on admission to the prison, she was found
to be anaemic and generally out of health. She said she had
coughed a good deal since the night of her arrest, at which time
she had lain several hours on the ground in a drunken stupor.
She was removed to the prison hospital on the 8th of May, two
days after her arrival. Her face was then pale and pinched,
cough incessant, pulse weak, temperature and respirations nor-
mal. A few coarse rales were heard in various parts cf the
chest, but no other physical signs of disease were discovered.
On the 10th of May her temperature rose to 100-2", and on the
11th to 102-4°, with a pulse of 90 and respirations 24 a min-
ute. This condition continue d until the 15th, when the tern
perature slowly declined to 99-6°, and the pulse became normal
On the 18th the sputum, which up to this time had been scan-
ty, became copious and consisted of frothy mucus of strongly
putrescent odor. The same odor was observed also when cough
ing occurred without expectoration, and also on forced expira
tion. She complained of great soreness in the left sub-scapular
region, increased greatly by the effort of coughing. Dullness
on percussion in this region now became manifest, and fine mu
cous rales were heard. Breathing grew more rapid, and on the
23d the temperature again rose to 101-fi°. The odor of the
breath was such as to be tolerated only by the freest ventilation
combined with the use of bromine and other disinfectants.
On the night of the 29th of May she raised a small quantity
of what appeared to be dark blood, after which amphoric res-
piration was heard below the left scapula, extending into the
infra-axillary region. During the week following the patient
seemed better, temperature and pulse returned to the normal,
respiration became easier, and the odor of the breath less foetid.
On the 7th of June, however, the temperature rose quite sud-
denly to 102° and did not again decline until the day of dearh ;
the pulse at no time went above 96. Respiration again became
very rapid and somewhat labored. The cough was incessant
when not quieted by opiates; sputum consisted of a frothy mu-
cus containing flecks of a brown putrescent substance which
settled to the bottom of the cup, in quantity from eighteen to
thirty-two ounces in the twenty-four hours ; its odor was hor-
rible in the extreme.
* Dr. Harris writes, since this paper was written, that Germany has
had eight operations after Sanger's method of suturing, two modified
(without the resection), and has saved six women and eight children.
\ Read before the Brooklyn Pathological Society, February 26, 1885.
On the night of June 15th, five weeks from the commence-
ment of the attack, she again raised several ounces of dark-
colored sputum, followed by a small amount of fresh blood.
The dulluess on percussion now extended higher, and amphoric
breathing was heard over the entire region below the spine of
the scapula; meanwhile a fairly good vesicular murmur was
heard in every other part of the chest.
On the 20th she again raised several ounces of semi-solid pu-
trescent matter, followed, as before, by a little fresh blood. From
this time she rapidly lost strength, and death occurred, appar-
ently from exhaustion, on the 30th of June— fifty-three days
after admission to the hospital. The treatment adopted wa9
from the first stimulant and tonic (mainly quinine and brandy),
with inhalations of turpentine, compound tincture of benzoin,
carbolic acid. etc. The latter part of the time morphine was
given freely to check the cough and give rest.
A post-mortem examination was made four hours after death
with the following result: Rigor mortis not established; skin
pale and bloodless; body not greatly emaciated ; adipose and
muscular tissues apparently normal. Pericardium and heart
normal ; valves of heart healthy. Right lung slightly catarrhal,
otherwise healthy. Pleura of left lung was much thickened;
its visceral and parietal layers were here and there firmly bound
together by adhesive bands, and the interspaces thus formed
were distended with putrescent gas, which escaped with a report
upon puncture.. Upper lobe catarrhal; superior portion of
lower lobe consolidated, while of the most dependent portion
behind nothing remained but a gangrenous, sloughing mass.
There was loss of tissue along the lower margin of the lung
anteriorly, giving it the appearance of having been gnawed.
Here and there a patch of cicatricial tissue told the story of
attempts at repair. No other cavity of the body was opened.
In the case before us, gangrene of the lung was doubt-
less the result of embolism and infarction. During the pro-
cess of softening of the gangrenous tissue, communication
with a bronchus was established, and, as it became liquefied,
it was expectorated.
An attempt at cicatrization was made again and again,
but each time enough of the putrid ferment remained to
renew the gangrenous process.
After a discharge of the necrosed portion the tempera-
ture and pulse declined to the normal, the breath lost much,
though not all, of its putrescent odor, the cough lessened,
and the patient imagined herself recovering, only to be dis-
appointed when the inflammatory process again was aroused
and another slough went through the process of separation.
The haemorrhage which followed each discharge came,
doubtless, from vessels or granulations on the line of demar.
kation.
" Gangrene of the lungs consists in death of lung tissue
associated with putrefaction, owing to the admission of
air." * Since the time of Laennec two forms have been de-
scribed, the circumscribed and the diffused ; of these, the
former occurs by far the more frequently. Fortunately,
gangrene of the lungs is not a common disease. But two
cases have occurred at the Massachusetts Reformatory Prison
for women since its establishment in 1877. At the Boston
House of Industry, on Deer Island, no cases have been re-
ported during that time, and but two have occurred at the
Boston House of Correction — institutions which together
represent about two thousand persons.
* Hertz in von Ziemssen'a " Cyclopaedia."
234
MOSTIER : PULMONARY GANGRENE.
[N. Y. Med. Joim.,
The disease is said to appear most often in the insane,
in drunkards and epileptics, and in children. A low state
of nutrition with weak heart-action is a predisposing
cause. An interruption of the blood-current, the passage of
foreign bodies into the air-passages, and traumatic influ-
ences, may be numbered among the chief exciting causes of
the disease. Obstruction of the blood-current may arise
fro7ii the pressure of pneumonic inflammatory exudate, or
hemorrhagic blood retained in the air-cells and intercellu-
lar tissue. It is, however, most often due to the passage of
an embolus into the pulmonary circulation. A minute vege-
tation from the valves of the right heart, a tiny clot picked
up somewhere in the venous circulation, or a fragment of a
thrombus from some purulent center, finds lodgment in a
pulmonary vessel. According to Cohnheim, rupture may
not occur at once ; the walls of the emptied vessel become
impaired through lack of nutrition, so that, when they arc
again filled by means of the collateral circulation, they are
too weak to bear the strain, and rupture occurs. The in-
farction thus produced may not extend beyond a single
lobule, and it may exceed the size of a hen's egg. Its favor-
ite seat, and consequently that of circumscribed gangrene,
is the lower border of the inferior lobes posteriorly (most
often the right).
It would seem that gravitation, as well as the ana-
tomical arrangement of vessels, has somewhat to do with
the site it chooses. The extravasated blood fills the air-
passages as well as their interspaces ; contact with air
rapidly produces decomposition, and the process is doubt-
less hastened by the development of vegetable parasites in
this most fertile soil* The irritation produced in the ad-
joining healthy tissue by the presence of a putrefactive fer-
ment results in localized inflammation which hastens the
process of separation.
Occasionally the gangrenous slough is expectorated in
toto and cicatrization occurs with recovery ; but more often
(as in the case which forms the basis of this paper) the pu-
trefactive ferment is never entirely removed, and repeated
attacks of inflammation occur, producing consolidation of
lung tissue, which, added to the poisonous influence of the
gangrene, rapidly exhaust the strength of the patient and
ultimately cause death. Haemorrhages frequently occur,
and are due to the sloughing of blood-vessels, or the blood
may ooze from wounded granulations on the line of demar-
kation. If the infarction is located near the surface of the
lung, the pleura participates in the inflammatory process.
Adhesions and thickening of the membrane follow, and
sometimes it also becomes gangrenous.
The physical signs of infarction are so obscure that an
early diagnosis is rarely made. Dullness on percussion
over a limited area, with an irritative cough, accompanied
by weak pulse and general malaise with pinched features,
is usually all that is observed until the inflammatory fever
arises and the breath becomes putrid. One needs but a
single whiff of this sickening odor to rei der a diagnosis
easy. It differs as widely from the fetor observed in some
cases of phthisis, and even from that of bronchiectatic cavi-
ties, as does the odor of necrosed nasal bones from that of
ill-smelling mucus.
Foreign bodies, as particles of food, etc., are sometimes
sucked into the air-passages, especially in the artificial feed-
ing of lunatics and paralyzed persons, and, by their rapid
decomposition or mechanical pressure, set up putrefactive
changes in the lung.
Gangrene from injury to the lungs, such as gunshot
wounds, stabs, etc., occasionally occurs, and it has been
known to result from severe contusions of the thorax, caus-
ing an effusion of blood into the lungs. The diffuse form
of gangrene frequently succeeds the circumscribed ; it also
occurs as a sequel to pneumonia and other diseases. In
this variety the lesion is most often found in the upper
lobes, and may involve a large portion of a lung.
The sputum in gangrene of the lungs is usually copious,
owing to the irritation of the bronchial mucous membrane
by the presence of putrid matter. It at first consists of a
frothy opaque mucus ; subsequently it becomes ash-gray,
green, or brown, and separates into two or three distinct
layers, the lower of which contains solid blackish particles
with soft yellow or brownish lumps, varying in size from
that of a hemp-seed to that of a bean. Under the micro-
scope the blackish flakes have been found to be shreds of
lung tissue which have undergone disorganization. They
are made up of granular matter and pigment cells, with
here and there a few elastic fibers. The soft yellow lumps
consist of fat globules with crystals of margaric acid.
Leyden and Jaffe * instituted a careful chemical exami-
nation of the sputum of gangrene, and found the products
of the decomposition of albuminous and fatty tissues — viz.,
myosin, leucin, margaric acid, traces of glycerin, volatile
fatty acids (mainly butyric, from which it largely derives
its odor), sulphide of ammonium, etc.
Up to the present time no treatment has proved effec-
tual in any number of cases. But few remedies adminis-
tered by the stomach, other than tonics and stimulants,
have been of any use; of these, carbolic acid and creasote
have their advocates, and Dr. Henry I. Bowditch, of Bos-
ton, has had good results from the use of liquor sodse
chlorinata?. Medicines used by inhalation, as recommended
first by Skoda in 1852, promise better results, but up to the
present time have been efficacious only in the most favor-
able cases. We have reason to hope, however, that, by
means of the "pneumatic differentiator" of Dr. Herbert
Williams, of Brooklyn, a new era in the treatment of pul-
monary gangrene, as well as in other diseases of the lungs,
has begun. There seems to be no doubt but remedies are
carried more deeply into the lungs by its use than by any
other known method, while the air imprisoned by an infarc-
tion or by abnormal secretions becomes by its expansion a
powerful vis a tergo for the removal of obstructing sub-
stances. Dr. Williams reports the treatment of a case of
"necrosis of lung caused by pressure of pleuritic- fluid."
As no mention is made of a putrescent odor, we can not con-
sider the case one of gangrene. The results of treatment,
however, were in many ways satisfactory and suggestive.
* Leptothrix pulmonalis, according to Leyden and Jaffe.
Von Ziemssen's " Cyclopaedia."
August 29, 1885.J
JONES: URETHRAL STRICT '(J RE.
235
Death occurs early in nearly all cases of diffused gangrene
of the lungs. The circumscrihed form is usually more
slow in its destructive action, and patients sometimes live
months. Recovery takes place in a limited number of cases,
but the prognosis is always a grave one.
URETHRAL STRICTURE ; CYSTITIS ; PYELO-
NEPHRITIS ; URINARY EXTRAVASA-
TION*
By CHARLES N. DIXON JONES, M. D.,
BROOKLYN.
S. 8., aged fifty-five, married, by occupation a wheelwright,
was admitted into the wards of the Brooklyn Hospital, June 16,
18«4, in a condition of exhaustion and stupor. The following
history was obtained: Early in life the patient contracted a
gonorrhoea, which ultimately resulted in a troublesome stricture.
From that time he has had much and increasing difficulty in
passing his urine. In 1870 he had an attack of acute cystitis;
at that time there is said to have been some paralysis, the exact
nature of which could not be ascertained. In 1882 he had an-
other attack of cystitis, since which time his difficulty in uriuat-
ting has steadily increased. Two weeks ago, while thus suffer-
ing, he was exposed to cold and wet ; since then he has had to
strain a great deal in order to pass his water at all.
Some uneasiness in the region of the perinaeum was com-
plained of, and a slight swelling was detected in this locality.
The scrotum was of a red color and shining in appearance.
The prepuce was long, and so contracted at the orifice that it
could not be retracted over the glans penis. At the meatus a
condition of hypospadias was observed. On passing the finger
into the rectum, the prostate was found to be somewhat en-
larged.
The urethra was first examined with a fair-sized instrument.
But it was only after considerable difficulty that I succeeded in
passing the finest whalebone bougie. By passing one bougie
after the other, and leaving them in position until all the folli-
cles were filled, I finally succeeded in passing one into the blad-
der. Along the side of the instrument, which was tied in the
bladder, the urine slowly dribbled away. In a short time the
patient succeeded in withdrawing the instrument from the
bladder. The urine was found to contain albumin and pus in
large quantities.
June 17th. — By the use of stimulants and proper nourish-
ment the patient's general condition had improved to some ex-
tent. Scrotum now much swollen and cedematous; perineal
swelling quite conspicuous. The patient was examined by Dr.
Speir, the attending surgeon, who kindly requested me to oper-
ate as soon as possible.
After careful setherization, the patient was placed upon the
operating- table. A filiform bougie was passed into the blad-
der and the strictures divided with a Maisonneuve's urethro-
tome. A steel sound was then introduced and external perineal
urethrotomy performed. A deep linear incision was made in
the oenter of the perinaeum, and a cavity, filled with pus and
urine, laid open and its contents evacuated. All sinuses and
abscesses were freely laid open and washed out with warm car-
bolic solution. A soft catheter was then passed through the
perineal wound into the bladder, and retained there. A drainage-
tube was inserted to the bottom of the abscess cavity and left
in situ. The scrotum was freely incised in several places. Dress-
ings saturated with a solution of liquor sodae chlorinatae were
* Read, with presentation of the specimens, before the Brooklyn
Pathological Society, February 26, 1885.
applied. The patient was then placed in bed surrounded with hot
bottles, and freely stimulated. The abscess cavity was washed
out every four hours with l-to-100 warm carbolic solution.
The urine passed away through the perineal wound, although
small in quantity.
The patient rallied somewhat after the operation, and, for a
time, seemed greatly improved. On the 21st the scrotum was
discolored and gangrenous. Patient dull and stupid ; skin cold
and clammy.
On the 23d, condition much the same. Temperature 97-5°
F. ; pulse quick and not so strong. Perineal wound presents an
unhealthy appearance.
On the 25th, a. m., quite feeble; does not take his nourish-
ment. Freely stimulated, p.m. Unconscious; pulse very feeble;
coma became profound, and remained so until death, which
occurred at 3.45 a. m., June 26th.
Post-mortem Examination. — At the autopsy, eight hours
after death, the body was found somewhat emaciated.
Lungs. — Right, cedematous. The left lung was intensely con-
gested and cedematous; bronchial tubes contained frothy mucus
and pus. Heart normal in size ; aortic valve thickened and in-
sufficient from old endocarditis; mitral valve thickened; liver
small and cirrhotic. Left kidney small, markings indistinct, pale
in appearance ; capsule non-adherent. Right kidney very small ;
it measures one inch and a half in length by three quarters of
an inch in diameter ; weight, two ounces and a half; substance
mostly replaced by fat; several small abscesses in substance of
kidney-tissue proper. Pelvis of both kidneys intensely con-
gested and covered with pus. Both ureters were dilated, with
thickened coats.
Upon microscopical examination, the kidneys presented the
lesions of chronic croupous nephritis, with waxy and fatty de-
generation. In the smaller kidney all the tissues had undergone
complete atrophy. The glomeruli had disappeared or were re-
placed by fibrous tissue. In the larger kidney, in addition to
the atrophied portions, there were certain districts where there
had been an increase in the amount of connective tissue, thus
constituting a true hypertrophy.
Bladder. — Cavity small and contracted ; hardly has a ca-
pacity of four ounces. "Walls very much hypertrophied ; the
mucous membrane thickened, thrown into ridges, which run in
various directions, forming crypts which contain pus. Surface
red and deeply congested, covered with pus. The condition in-
dicated long-continued chronic cystitis.
Urethra. — By laying open the urethra, two strictures were
found — one about three inches and the other five inches from
the meatus. Prostate enlarged.
In the floor of the urethra there is a small opening which
communicates with an abscess cavity in the perinaeum three
inches in diameter. Scrotum in a sloughing condition.
The follicles in the membranous portion of the urethra are
inflamed, and from these cavities a drop of pus may be pressed.
One, much larger than the rest, presents an opening through
which a probe may be passed into the abscess cavity.
The case presented is of interest chiefly from a patho-
logical point of view, for, as is demonstrated by the au-
topsy, when the patient came under observation the morbid
changes in several of his most vital organs had advanced to
a stage where they were beyond the reach of surgical skill.
In tracing the pathological sequence in the above case,
several points are to be noted :
1. The beginning of his trouble was a gonorrhu-a ac
quired in early life.
Sir Henry Thompson claims that the urethra is not a
236
SEXTON: NOMENCLATURE OF AURAL DISEASES.
[N. Y. Med. Jock.,
tube, but a continuous closed valve. Its length renders it
liable to disease and accident — "the price — and a heavy
one, let me tell you — which the uale pays for his specially
distinguishing feature."
Remembering this fact, it is easy to see how an inflam-
matory process affecting this passage, which is so richly
supplied with blood and nerves, leads to secondary patho-
logical results which affect the prostate gland, bladder, ure-
ters, and kidneys. The testes, penis, seminal vesicles,
perinreum, and rectum share, not unfrequently, in the same
pathological process. The urethritis destroys the natural
elasticity of the canal. The elasticity of the urethral walls
being thus lost, the urine can not escape so readily, hence
the resulting hypertrophy of the bladder. The bladder
which has undergone hypertrophy can not completely empty
itself. It is estimated by Ultzmann that a patient who, at
twenty or thirty, has a residue of only 20 c. c. remaining in
the bladder after urinating, will have from 200 c. c. to 300
c. c. at fifty, with accompanying hypertrophy. The urine
which remains is mingled with pus-corpuscles, and under-
goes alkaline fermentation. Bacteria are developed, and
the inflammation is liable to extend through the ureters to
the kidneys.
2. The specimen presented demonstrated the extremely
unhealthy condition of the kidneys. The nephritis from
which the patient suffered must have been of long standing.
We all know the extremely unfavorable influence which any
form of nephritis exerts upon all operations on the urinary
organs.
In considering the kidney lesion in this case, the com-
plicating cardiac and hepatic lesion must be taken into
consideration. The condition of the heart can not be con-
sidered merely an accidental complication. By some writ-
ers on this subject the cardiac complication has been con-
considered the most important part of the disease. Dr.
Mahomed speaks of cases of Bright's disease which die
without nephritis. He drew attention to the fact that
Bright's disease is often a general and not a simply local
disease.
From the history of the case presented, it would appear
that the stricture of the urethra was an efficient cause in
producing the renal disease, yet the form of nephritis found
is not such as we usually meet with in such cases. The
question arises, Was not the kidney lesion independent of
the urethral stricture ? Opposed to this view is the absence
of cardiac hypertrophy and the condition of the bladder and
ureters, which correspond to the conditions that are fre-
quently found, after old neglected urethral stricture.
The theories in regard to the interdependence of renal
and cardiac disease are too numerous, complicated, and un-
settled to allow of discussion at this time. The sequence of
events in this case seems to have been urethral stricture,
cystitis, pyelitis, and nephritis.
3. Dittel, of Vienna, was the first to show that in cases
where death resulted from urinary extravasation the open-
ing by which the urine slowly infiltrated the loose connec-
tive tissues was through an ulcerated follicle of the mucous
membrane of the urethra. Prof. Otis has fully elaborated
this theory, and shown the influence which a stricture of
either large or small caliber exerts in producing this patho-
logical result. A stricture so slight that it would admit the
easy passage of a catheter would be sufficient to retain the
organic debris of a person suffering with lithiasis; or, from
increased urinary irritation at a point of stricture, a fol-
liculitis is set up which may eventually result in suppurative
inflammation and perforation of the urethral wall. This is
probably what occurred in the case above recorded.
In the history of this case, although obtained with diffi-
culty, there is nothing to indicate that a sudden rupture of
the urethral wall had taken place, such as sometimes occurs
behind a stricture during some violent act of straining, with
extensive extravasation of urine into the intercellular spaces.
NOMENCLATURE OF AURAL DISEASES.
By SAMUEL SEXTON, M. D.,
SURGEON, NEW YORK EYE AND EAR INFIRMARY.
Introductory Note. — I have been requested to publish
for the use of others the following nomenclature, which
was prepared for my own convenience. In the arrange-
ment no little difficulty was experienced in reconciling the
opinions of various writers in respect to certain affections
of the ear, but it is believed that the classification, imper-
fect as it necessarily must be, may afford some assistance to
others who, like the writer himself, have felt the need of
such a work of reference. Not to mention minor defects,
it is to be regretted that the comparatively undeveloped
pathology of the inner ear prevents a complete classification
of its diseases. In the final arrangement of the work of
classification I have been very much assisted by Dr. Robert
Barclay, Assistant Surgeon, New York Eye and Ear In-
firmary.
DISEASES OF THE EAR
EXTERNAL EAR AURICLE.
I. Abnormalities.
a. Arrested development.
1. Abnormal position.
2. Absence of auricle, or parts of auricle, and
altered shape, as lapping, convolutions, due
to absence of cartilage.
3. Microtia.
4. Congenital fistula.
b. Excessive development.
1. Plurality.
2. Abnormal enlargement.
3. Polyotia (Auricular appendages).
4. Reduplication.
c. Irregular development (?).
II. Cutaneous Diseases.
a. Callosities.
b. Comedo — Acne punctata [Sebaceous tumor?].
c. Dermatitis.
d. Eczema.
e. Erysipelas.
/. Erythema, Flushing.
g. Furuncle, Abscess.
k. Gangrene [from Embolism, Low Fevers, or
Freezing].
August 1000.| OJlJIl/ii.' jii/amii/ofliui.
?*. Herpes zoster (Auriculae idiopathica).
2. From septic infection.
Hvdroa.
3. " poisoned weapons.
jfc. Ichthyosis (congenita).
EXTERNAL AUDITORY CANAL.
/ Tntortrio'o
i.
Abnormalities.
w Tveloid
11%/* _l V 1 ' ' ' ' ■
a. Arrested development.
w. Leprosy.
1. Absence of external auditory canal.
o. Lupus (erythematosus, maculosus, exulcerans).
2. Atresia congenita (membranosa, ossea).
_p Molluscum fibrosum.
3. Abnormal width.
^. Myxoderma [a neurosis whose aetiology is unde-
4. Congenital contraction.
termined].
b. Excessive development.
r. Naevus.
1. Thickening of cutaneous lining. [ Vide New
s. Pemphigus gangrenosus.
Growths.!
j
t. Pernio [Frost-bite].
c. Irregular development.
u. Phagedaena [Cancrum oris].
1. Meatus bivius.
v. Phlegmon (acute, chronic).
ii.
Hyperemia.
w. Syphiloderma (erythematosum, papulare, tuber-
hi.
Periostitis.
culare, pustulare, squamosum, serpiginosum,
IV.
Circumscribed Inflammation.
ecthymatosum, ulcerativum, nodosum).
v.
Diffuse Inflammation (acute, chronic).
x. Tophi.
VI.
Croupous Inflammation.
y. Trichophytosis [Ring-worm].
VII.
Ganqrenous Inflammation.
z. Ulcer.
VIII.
Desquamative Inflammation.
III.
New Growths.
IX.
Extravasative Inflammation.
a. Angioma — Glandular hypertrophy.
X.
Skin Diseases.
b. Cavernous tumor.
a. Eczema.
c. Cyst (dermoid, sebaceous). Atheroma, cornu.
b. Erysipelas.
[Comedo? Acne punctata?]
c. Erythema.
d. Cornu. [ Vide Cyst.]
d. Herpes.
e. Epithelioma.
e. Pemphigus.
f. Fibroma.
f. Ulcer, haemorrhage.
g. Fibrosarcoma.
XI.
Anomalies of Secretion.
h. Lipoma, Steatoma [Atheroma?].
a. Cerumen (deficiency, excess), Cretaceous Bodies,
i. Myxofibroma.
Otomycosis (Aspergillus Nigricans, A. Fla-
j. Myxosarcoma.
vescens, A. Fumigatus, Graphium Penicil-
k. Naevus vascularis [maternus].
loides, Aschophora Elegans, Trichothecium,
I. Sarcoma.
Mucor Mucedo seu Fuscus, Otomyces Ha-
m. Haematoma. [ Vide Wounds and Injuries.]
geni, 0. Purpureus).
IV.
IVounds and Injuries.
b. Seborrhoea,
a. Cleft of lobule [by ear-ring].
c. Desquamation, laminated epithelial plug.
b. Lacerated wound.
XII.
Stricture Stenosis.
c. Contused wound. Haematoma [Othoemato-
XIII.
Adhesion of Walls — Bands.
ma].
XIV.
Collapse of Cartilaqinous Portion.
d. Incised wound.
XV.
Caries and Necrosis — Communicating sinus from
e. Punctured wound.
parotid gland, attic of tympanum, or adja-
f. Shot wound.
cent pneumatic cells.
g. Effects of heat.
XVI.
Granulation — Haemorrhage.
1. Burns.
XVII.
New Growths.
2. Scalds.
a. Enchondroma.
h. Effects of cold.
b. Epithelioma.
1. Frost-bite.
c. Exostosis (pedunculated, broad-based).
2. Gangrene.
d. Hematoma.
3. Chilblains.
e. Hyperostosis.
i. Effects of mineral and vegetable irritants.
f. Milium.
1. From acids.
a. Thickeninsr of cutaneous lininsr of canal. T Vide
wo o L
2. " austic alkalies.
Abnormalities.^
3. " metallic compounds.
h. Polypus.
4. " acrid vegetables [Nettle, etc.].
o L 7 J"
i. Sarcoma.
j. Effects of poison in wounds.
j. Sebaceous tumor.
1. From bites of insects, reptiles, and other ani-
XVIII. Wounds and Injuries.
mals.
a. Lacerated wound.
238
SEXTON: NOMENCLATURE OF AURAL DISEASES.
[N. Y. Mkd. Jour.,
b. Contused wound.
c. Incised wound.
d. Punctured wound.
e. Shot wound.
/. Fracture. [ Vide Wounds and Injuries of Auri-
cle.]
XIX. Foreign Bodies.
a. Animate objects.
b. Inanimate objects.
XX. Ingrowing Hairs from Tragus and Canal pressing
upon the Membrana Tympani.
MEMBRANA TYMPANI.
I. Abnormalities.
a. Arrested development.
1. Absence of manubrium mallei.
2. Absence of membrana tympani.
b. Excessive development.
c. Irregular development.
II. Trophic Changes.
a. Atrophy.
b. Calcareous degeneration.
c. Opacity — Fibrous hypertrophy (?).
d. Cicatricial regeneration [manometric].
III. Myringitis, Simplex.
a. Inflammation of pars flaccida (acute, chronic).
b. Inflammation of pars vibrans (acute, chronic).
IV. Myritigitis, Desquamative.
V. Myringitis, Extravasative [Haematoma of drum-head].
VI. Abscess.
VII. Chronic Ulcer — Haemorrhage.
VIII. Wounds and Injuries.
a. Rupture.
1. From boxing auricle.
2. From pulling auricle.
3. From falling on auricle.
4. From syringing canal.
5. From condensing air in canal or Eustachian
tube.
6. From rarefying air in canal or Eustachian tube.
1. From fracture of base of skull.
b. Perforation by puncture, or incision, with foreign
body, or instruments.
e. Abrasion from impacted cerumen, foreign body,
or instruments.
d. Concussion from impacted cerumen, foreign
body, or instruments.
e. Straining from pulling auricle.
f. Effects of cold from bathing, diving, or syring-
ing canal.
IX. Skin Diseases.
a. Eczema.
b. Erysipelas.
c. Erythema.
X. New Growths.
a. Cholesteatoma.
b. Epithelioma.
c. Syphilide.
d. Tubercle.
e. Vascular tumor.
XI. Foreign Bodies.
a. Animate objects.
b. Inanimate objects.
MIDDLE EAR TRACT TYMPANUM ATRIUM, ATTIO, AND
ANTRUM.
I. Abnormalities.
a. Arrested development.
1. Absence of membrana tympani.
2. Absence of part or all of ossicles.
3. Absence of tympanum.
4. Absence of labyrinthine fenestras.
5. Absence of eminentia pyramidalis.
b. Excessive development.
1. Fusion of ossicles.
2. Overgrowth of ossicles.
3. Superfluous ossicles.
c. Irregular development (?).
II. Haemorrhage — Vicarious menstruation.
III. Acute Nonsuppurative Otitis Media.
IV. Mucous or Muco-serous Catarrhal Otitis Media
(acute, subacute, chronic — trophic).
V. Suppurative Otitis Media (acute, subacute, chronic).
VI. Croupous, Diphtheritic, and Desquamative Otitis Me-
dia.
VII. Caseous Otitis Media.
VIII. Chronic Dry and Adhesive Catarrhal Otitis Media.
IX. Sclerosis.
X. Caries of Tympanum.
XI. Caries of Ossicles.
XII. Fracture and Dislocation of Ossicles.
XIII. Syphilitic Inflammation of Tympanum (secondary,
tertiary).
XIV. Wounds and Injuries.
a. Through Eustachian tube.
b. Through membrana tympani.
c. By fracture of base of skull.
XV. Embolism in Mucous Membrane.
XVI. New Growths.
a. Cholesteatoma.
b. Cyst.
c. Epithelioma.
d. Exostosis of tympanum.
e. Exostosis of ossicles.
/. Hyperostosis of tympanum.
g. Hyperostosis of ossicles.
h. Osteosarcoma.
! mucous J muco-fibrous.
fibrous ) c,
v myxo-nbrous.
mucoid )
j. Tubercle.
XVII. Foreign Bodies.
a. Animate objects.
b. Inanimate objects.
COMPLICATIONS OF DISEASE OF MIDDLE EAR TRACT.
I. Periostitis of Cortex of [osseous] Ext. Auditory Canal.'
II. Disease of Mastoid Process.
a. Periostitis of coitex of mastoid process.
b. Inflammation of pneumatic cells of mastoid
process (catarrhal, purulent, cheesy — acute,
August 29, 18S5.J auATUa: iv urn n:\ ula i u ten un aukal, lnsuAdUis. ijyy
chronic). [All inflammations of the tym-
b. Excessive development.
panum are apt to involve, in secondary inflam-
1. Very large pneumatic cells.
mation, the pneumatic cells of the mastoid
c. Irregular development.
process, and vice versa.]
1. Anomalous character of blood-channels.
c. Caries and necrosis of mastoid process.
II.
Haemorrhage.
d. New growths of mastoid process.
III.
Inflammation of Pneumatic Cells, Catarrhal {Pri-
a. Cholesteatoma.
mary).
b. Epithelioma.
IV.
Inflammation of Pneumatic Cells, Purulent (Pri-
c. Exostosis.
mary).
d. Hyperostosis.
V.
Periostitis Externa.
e. Polypus. [ Vide Polypus of Middle Ear Tract.]
VI.
Caries and Necrosis.
III. Circumauricular Abscess.
VII.
Sclerosis (?). [Closing of pneumatic cells by ossifi-
IV. Facial Paralysis [Bell's Palsy].
cation in old age.]
V. Fracture of Base of Skull.
VIII.
Wounds and Injuries.
VI. Pachymeningitis.
a. Contused wounds.
VII. Leptomeningitis. .
b. Perforated wounds.
VIII. Cerebral Abscess.
c. Fracture.
IX. Thrombosis.
d. Shot wounds.
X. Embolism.
IX.
New Growths.
XI. Phlebitis.
a. Cholesteatoma.
XII. Pyazmia.
b. Epithelioma.
XIII. Constitutional Disease.
c. Exostosis.
a. Rheumatism.
d. Hyperostosis.
6. Phthisis.
e. Polypus. [Vide Polypus of Middle Ear Tract.]
c. Rhachitis.
X.
Foreign Bodies.
d. Syphilis.
a. Animate objects.
e. Exanthemata.
b. Inanimate objects.
L Scarlet fever.
2. Typhus fever.
COMPLICATIONS OF DISEASES OF THE MASTOID PROCESS.
3. Typhoid fever.
I.
Diseases of External Ear, and their Complications.
4. Measles.
II.
Diseases of Middle Ear Tract, and their Complica-
5. Variola.
tions.
6. Varioloid, etc.
III. Diseases of Internal Ear, and their Complications,
/. Whooping-cough.
IV.
Simis of Neck.
g. Diphtheria.
V.
Torticollis.
h. Bright's disease.
INTERNAL EAR.
i. Diabetes.
I.
Abnormalities.
/. Genito-sexual disturbance.
a. Arrested development.
l. 1 liberty.
1. Absence of part or all of the labyrinth.
2. Pregnancy.
2. Absence of auditory nerve.
3. Menopause.
b. Excessive development.
4. Masturbation.
c. Irregular development (?).
5. Excessive venery, etc.
II.
Anaemia.
k. Abuse or systemic materia medica.
III. Hyperemia.
A1V. Ural Irritation or Disease.
IV.
Haemorrhage.
AV, Orbital Irritation or Disease.
V.
Otitis Interna, Simplex.
VTTT XT IT ' i t ' T\ '
AVI. JSasal Irritation or Disease.
VI.
Otitis Interna, Syphilitica (?).
AV11. Pharyngeal Irritation or Disease.
VII. Otitis Interna, Typhoidea (?).
XVIII. Mumps.
VIII.
Otitis Interna, Parotitica (?).
XIX. Disease oj External Ear.
IX.
Caries and Necrosis.
XX. Disease of Internal Ear.
X. Wounds and Injuries.
MASTOID PROCESS.
a. Through middle ear.
b. By fracture of base of skull.
I. Abnormalities.
c. Concussion.
a. Arrested development.
XI. Diseases of Auditory Nerve.
1. Ossification gaps in outer table.
a. Hyperamiia.
2. Absence of pneumatic cells.
b. Inflammation.
3. Separation from rest of temporal bone.
c. Atrophy.
4. lotal absence ot mastoid process.
d. Amyloid degeneration (Corpora amylacea)..
240
GARRIQUES: FAILURE OF COCAINE.
fN. Y. Med. Joch.,
e. Injury or paralysis.
f. New growths.
1. Fibroma.
2. Fibro-sarcoma.
3. Glioma.
4. Gumma.
5. Neuroma.
6. Sarcoma.
COMPLICATIONS OF DISEASE OF INTERNAL EAR.
I. Associated Disease (local or constitutional).
II. Brain Disease or Injury.
III. Fracture of Base of Skull.
IV. Disease of Middle Ear Tract, and [its Complica-
tions.
V. Disease of Mastoid Process, and its Complications.
EUSTACHIAN TUBE.
I. Abnormalities.
a. Arrested development.
1. Congenital absence.
2. Congenital obliteration or stenosis.
3. Angular bends.
4. Ossification gaps in wall of carotid canal.
5. Malposition of pharyngeal orifice.
b. Excessive development.
1. Congenital widening.
c. Irregular development.
II. Haemorrhage.
III. Inflammation, Catarrhal (acute, chronic).
IV. Inflammation, Purulent [acute, chronic).
V. Inflammation, Croupous and Diphtheritic.
VI. Ulcer.
VII. Contraction.
VIII. Enlargement.
IX. Adhesions and Closure.
X. New Growths.
a. Exostosis.
b. Fibroma.
c. Syphiloma.
d. Tubercle.
XI. Foreign Bodies.
a. Animate objects.
b. Inanimate objects.
XII. Diseases of the Tubal Muscles.
a. Fatty degeneration and atrophy.
b. Hypertrophy.
c. Trichinosis.
d. Hcemorrhagic infarctions.
e. Paresis.
COMPLICATIONS OF DISEASE OF EUSTACHIAN TUBE.
I. Inflammation, Injury, New Growth, Foreign Body
in Pharynx.
II. Inflammation, Injury, New Growth, Foreign Body
in Nares.
III. Inflammation, Injury, New Growth, Foreign Body
in Middle Ear.
IMPORTANT SYMPTOMS OF EAR DISEASE.
I. Neuralgia.
II. Aural Vertigo.
III. Anomalies of Audition.
a. Autophonia, Tinnitus, Numbness.
b. Pseudacousma.
IV. Neuroses [Reflex phenomena].
a. Pruritus auris.
b. Ear cough.
c. Epileptiform convulsions.
d. Otalgia.
e. Dysacousma.
MISCELLANEOUS.
I. Mumps (resulting in Resolution, Suppuration, or Me-
♦ tastasis).
II. Tonsillar Diseases.
III. Inflammation, Injury, New Growths, Foreign Bodies
of the Upper Respiratory Tract.
FAILURE OF COCAINE HYDROCHLORATE
TO PRODUCE ANAESTHESIA.
By HENRY J. GARRIGUES, M. D.
Recently I had to perform an operation in order to
restore to an available condition a vulva which, in a peri-
neorrhaphy performed by another surgeon, had been closed
up to such an extent as barely to admit the index-finger
and not the organ to which it physiologically is destined to
give passage.
The patient was a married woman, thirty-seven years of
age. I had to cut fully one inch backward from the arti-
ficial posterior commissure, after which I united the skin
with the mucous membrane by sutures.
Since here was only a thin layer of skin and mucous
membrane to be cut, both surfaces of which were easily
accessible, it seemed to be a case peculiarly well fitted for
local anaesthetization. I began by painting both surfaces
with a four-per-cent. solution of hydrochlorate of cocaine.
When two grains of the salt had been used in this way
and there was not the slightest diminution in the sensi-
tiveness of the skin, I injected a quarter of a grain hypo-
dermically into the tissue to be divided, and continued
soaking the skin and the mucous membrane. About seven
minutes after the first hypodermic injection I repeated it,
introducing the needle from the posterior commissure all
the way back as far as the tissues were to be divided. In
spite of the previous injection, this caused as much pain as
if nothing had been done before to produce anaesthesia.
This second time, likewise, a quarter of a grain of the
salt was injected slowly, while withdrawing the needle, over
the whole tract with which it came in contact. Finally I
bathed again the two surfaces until I had used in all five
grains of hydrochlorate of cocaine, one half grain of which
had been injected hypodermically. This application of a
four-per-cent. solution had then been kept up for twenty-
five minutes.
In spite of this thorough and protracted application of
August 29, 1885.|
BOOK NOTICES.— LEADING ARTICLES.
241
a comparatively strong solution of cocaine, the sensibility-
was not lessened the least, so far as the complaints and
screams of the patient could be used as a measure of her
pain.
The price of the cocaine used was two dollars.
Ernst Frankel, of Breslau (" Centralblatt fur Gynakolo-
gie," December 6, 1884, vol. viii, p. 778), has likewise found
the common solutions ineffective on the vagina, and recom-
mends a twenty-per-cent. alcoholic solution ; but, when we
take into consideration the high price of the drug, so ex-
pensive a solution can only be used in exceptional cases.
The patients, unless money be no object at all, will prefer
to stand the pain or to be etherized.
BOOKS AND PAMPHLETS RECEIVED.
Contributions to the Topographical and Sectional Anatomy
of the Female Pelvis. By D. Berry Hart, M. D., F. R. 0. P. E.,
Lecturer on Midwifery and Diseases of Women, School of Medi-
cine, Edinburgh, etc. Edinburgh and London : W. & A. K.
Johnston, 1885. 4to, pp. 8, xii plates.
List of Tests (Reagents), arranged in Alphabetical Order
according to the Names of the Originators. Designed especially
for the convenient reference of Chemists, Pharmacists, and Sci-
entists. By Hans M. Wilder. New York: P. W. Bedford,
1885. Pp. 88.
Double Congenital Displacement of the Hip. Description
of a Case, with Treatment resulting in a Cure. (With Plates.)
By Buckminster Brown, M. D., Consulting Surgeon of the
House of the Good Samaritan, etc. Boston : Cupples, Upham,
& Co., 1885. Pp. 24.
Report of the Department of Health, City of Chicago, for
the Years 1883 and 1884. Chicago : G. K. Hazlitt & Co., 1885.
Pp. 172.
University of the City of New York, Medical Department.
Forty-fifth Annual Announcement.
Catalogue of the Albany Medical College, and Annual An-
nouncement for the Session of 1885-1886.
University of Denver. Fifth Annual Announcement of the
Faculty of Medicine.
The Constitutional Treatment of Caries and Necrosis. By
Hal C. Wyman, M. D., Professor of Physiology and Histology
in the Michigan College of Medicine, Detroit. Pp. 7.
Report- upon the Epidemic of Typhoid Fever at Plymouth,
Pa. Read by appointment before the Luzerne County Medical
Society of Wilkesbarre, Pa., May 21, 1885, and before the State
Medical Society of Pennsylvania, at Scranton, May 29, 1885.
By Lewis H. Taylor, M. D., of Wilkesbarre. Pp. 25.
Asiatic Cholera. A Sketch of its History, Nature, and Pre-
ventive Management. By Oscar C. De Wolf, M. D., Commis-
sioner of Health, Chicago, etc. Chicago: The American Book
Co., 1885. Pp. 17. [Price, 12 cents ]
Quarterly Station-Li<t of Officers of the Medical Department
and Hospital Stewards, United States Army, July 1, 1885, or at
date of last report received at this office. Washington : Sur-
geon-General's Office.
Surgical Notes from the Case-Book of a General Practitioner.
By William C. Wile, M. D., of Sandy Hook, Conn. [Reprinted
from the "New England Medical Monthly."]
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Poster, M. D.
NEW YORK, SATURDAY, AUGUST 29, 1885.
THE SPECIAL MEETING OF THE CONGRESS COMMITTEE.
As we have already notified our readers, the American
Medical Association's new Committee on the International
Medical Congress is to hold a special meeting in New York on
Thursday of next week. Regardless of what action may be
taken, the mere fact that such an extraordinary meeting is to be
held, after the committee had concluded its work of demolition
and adjourned until next spring, is a gratifying proof that the
spontaneous and widespread dissent that has been expressed by
the better portion of the profession from the absurd course laid
out by the American Medical Association has not failed to pro-
duce an effect. It is the most decided and unmistakable of
numerous indications that a change has come over the spirit of
the New Orleans agitators' dream.
It is to be presumed that the meeting will undertake little
else than the repair of damages — that is, the appointing of
others to take the places of the distinguished men who have
declined to take part in the present organization. That any
such action will fail of its purpose seems to us unquestionable.
We do not doubt, indeed, that men enough can be found who
will be willing and even glad to hold official positions in a
gathering that will be international only in name. But, allow-
ing that the committee made the best choice it could have made
at Chicago, any selections that it makes now must necessarily
be of inferior men, and it is doubtful even if men a grade below
those first chosen would be willing to figure before the world
as the recipients of appointments that had gone begging. It
can scarcely be doubted, therefore, that the corps of appointees
will be largely inferior to the remnants left by the recent defec-
tions. Far from having been mended, matters will then have
been made worse ; but, if this is to be the result, it is best that
it should come promptly, that the remedy may follow the more
speedily.
Besides patching up the organization, the committee may
try to palm off upon the country something having the sem-
blance of a compromise as to the qualifications of those who
are to be allowed to take part in the Congress non-officially, but
it will be surprising if anything remotely resembling decency is
put forward in this direction — in fact, nothing of the sort is
possible except a complete reversal of the tinkering that the
organization has undergone.
By this time the plotters who are behind the committee un-
doubtedly understand that it will profit them nothing to pursue
the petty scheme of inducing Dr. Shoemaker to play the part of
a scapegoat and resign, although it is but a few weeks since
they professed in private to count confidently upon that sop to
Cerberus.
242
MINOR PARAGRAPHS.
[N. Y. Mki/. Jouk.,
There is one plain course open to the committee, and one
only, by which it may save its own credit and do the only thing
possible to rescue the Congress from destruction — and that is,
to rescind everything it lias thus far done, and to resolve to ask
the American Medical Association to discharge it. This would
practically restore the old organization, and, although it would
come rather late, might result in reviving the bright prospects
of the Washington Congress as they existed six months ago.
THE POSTURES OF SCHOOL CHILDREN.
An English surgeon, Mr. Noble Smith, who is connected
with a children's hospital, and who appears to have something
to do officially with the Board Schools of London, lately read a
Tery important paper before the Medical Officers of Schools As-
»ociation, which is published in the "Medical Times and Ga-
zette." The title of Mr. Smith's paper is " Postures in School,
and their Influence upon the Figure." He deals, however, not
only with the influence of strained and unnatural postures upon
the figure, but also with their effect upon health and strength
in other ways, and with a number of collateral matters relating
to school hygiene, such as the management of the light used for
reading and writing, etc.
In one instance he measured the distance between the
pupil's eyes and the copy-book, and found it to be only two
inches and a half. It does not appear that this was the result
of nearsightedness on the part of the pupil, but of faulty con-
struction of the desk, which was too low and removed too far
from the pupil's body. From these and various other defects
in the arrangement of the chair and desk, and from certain en-
forced attitudes which are supposed to favor an elegant hand-
writing, roundness of the back and lateral curvatures of the
spine were found to be frequent results. The author calls atten-
tion to the deleterious effects of all this upon the individual,
especially as regards the breathing capacity. Girls are most
affected, as they are held to a more rigid observance of postures
that are deemed decorous, while at the same time they are in
great measure denied the counterbalancing effects of free and
unrestrained play, their diversion being too often restricted to
a prim and stately walk in couples.
Of late years, much attention has been given to these mat-
ters in the United States, and the result has been a very decided
improvement, but it is very much to be feared that we are not
yet altogether free from the evils that are so vividly depicted
by Mr. Smith as occurring among the school children of
London.
MINOR PARAGRAPHS.
AN ACCIDENT IN A PARIS HOSPITAL.
A deplorable mistake was lately made at the St. Louis
Hospital, in Paris, which resulted in the death of two patients.
According to the account given in the "Progres medical," a
preparation popularly termed eaude-vie alltmande, which is a
compound tincture of jalap, was ordered by the phy.-iciau, but
the pupil on duty in the pharmacy put up gouttes ameres de
Beaume instead, the latter being a mixture containing ignatia.
The pupil is described as having been wild with despair when
he learned of the fatal consequences of his error, and another
account states that it was with difficulty that he was prevented
from committing suicide. "Progres medical" is probably cor-
rect in its suggestion that the "reactionary " newspapers would
have been loud in their outcries if the affair had happened in
one of the hospitals where lay officials are employed.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Health Department for the following
statement of cases and deaths reported during the two weeks
ending August 25, 1885 :
DISEASES.
Week ending Aug. 18.
Week ending Aug. 25.
Cases.
Deaths.
Cases.
Deaths.
Typhus
0
0
1
0
Typhoid fever
23
6
29
10
Scarlet fever
25
4
14
4
Cerehro-spinal meningitis. . . .
1
1
Q
1- -
Measles
31
3
12
6
Diphtheria
30
16
31
17
Yellow fever
1
0
0
0
The Health of Foreign Cities.— We are indebted to the
secretary of the National Board of Health for the following
abstract of reports from our consuls, received at his office since
the date of the last bulletin, August 12th. Three Riven, Cana-
da.— For the week ending August 8th : Free from epidemic
diseases. The consul reports that there is no small-pox below
Montreal, where there has been a total of 120 deaths up to the
end of the second week in August. Havana, Cuba. — For the
week ending July 30th: 25 cases of yellow fever and 3 deaths.
Cardenas, Cuba. — For the two weeks ending August 8th: Free
from cholera and yellow fever. Matanzas, Cuba. — For the week
ending August 5th : No cholera or yellow fever. Cienfuegos,
Cuba. — For the week ending July 15th : No cholera or yellow
fever. St. Thomas, W. I. — For the week ending July 25th : In-
testinal catarrh and acute diarrhoea prevalent, but in a mild
form. Very few fatal cases. Nassau, N. P. — For the week
ending August 1st : No epidemic diseases. Curacoa,W. I. — For
the week ending August 15th : In good sanitary condition.
Guaymas, Mexico. — For the month of July : City and district in
good sanitary condition. Vera Cruz, Mexico. — For the month
of July : 84 deaths from yellow fever. The disease is said to be
epidemic. Acapulco, Mexico. — For the week ending July 26th :
Free from epidemic diseases. Callao, Peru. — For the week
ending July 18th : Yellow fever has disappeared, but small-pox
prevails among the lower classes. La Guayra, Venezuela. — For
the week ending August 8th: In good sanitary condition.
London, England. — For the week ending August 8th : Deaths
from diarrhoea and dysentery, 309; from cholera or choleraic
diarrhoea, 11, and from small-pox, 14, including 9 of London
residents who died from the disease outside the registration dis-
trict. On August 8th there were 518 cases of small-pox in the
London hospitals, being 96 less than in the previous week. The
admissions during the week were 43, there having been 69
during the preceding week. Bristol, England. — For the week
ending August 8th: 1 death from cholera. Paris, France. —
For the two weeks ending August 8th : 61 cases and 3 deaths
from small-pox, 213 cases and 36 deaths from typhoid fever.
Bordeaux, France. — For the month of July: 4 deaths from
small-pox. Marseilles, France. — By cable, August 25th : Deaths
from cholera average 55 daily. Toulon, France. — By cable)
August 25th : 25 deaths from cholera on the day previous.
Barcelona, Spain. — For the week ending July 31st: 1 death
Augnst 29, 1885.]
from small-pox; 36 deaths from unclassified contagious dis-
eases; gastric and intestinal catarrh prevalent. Antwerp, Bel-
gium,— For the two weeks ending August 1st: 26 cases and 5
deaths from small-pox. Cadiz, Spain.— For the week ending
August 8th: Free from epi.lemic diseases. Valencia, Spain. —
For the two weeks ending August 2d : 785 cases of cholera aud
369 deaths. Genoa, Italy— For the week ending August 2d :
1 death from small-pox. Venice, Italy.— For the two weeks
ending August 1st: 20 deaths from small-pox. Trieste, Aus-
tria.—For the week ending August 1st: 6 cases of small-pox
and 2 deaths. Prague, Austria.— -For the week ending August
6th: 2 deaths from small-pox. St. Petersburg, Russia.— For
the week ending July 25th : 6 deaths from small-pox. Warsaw,
Russia. — For the two weeks ending August 1st: 9 deaths from
small-pox. Calcutta, India.— For the week ending July 4th :
16 deaths from cholera. Bombay, India.— For the week end-
ing June 30th : 6 deaths from cholera as against 2 during the
previous week.
The Cholera in Spain. — According to information received
by the "Gazette hebdomadaire de med. et de chir.," there had
been, up to July 31st, 114,714 cases and 34,003 deaths. In
Madrid the number of cases was 4,058, with 1,353 deaths. The
number of infected towns was upward of 380.
Typhoid Fever is reported as being prevalent in the Lunatic
Asylum at Morris Plains, N. J., thirteen oases having already
occurred, with but one death. The outbreak of the disease is
attributed to defective sewerage.
Scarlet Fever has, it is alleged, been conveyed from an in-
fected family to others in Jamesport, Long Island, by the total
disregard of instructions from the Board of Health, who or-
dered the father to quarantine the family, the man contending
that the disease was not contagious, and permitting members
of his family to go and come at will. He is likely to pay the
penalty of his disobedience and ignorance.
The International Medical Congress.— We learn that Dr.
Delavan Bloodgood, Medical Director in the navy, has declined
to hold the position to which he was appointed by the new
committee. As will be seen by his letter, printed in another
column, Dr. Alfred L. Carroll, the secretary of the New York
State Board of Health, has also pursued the same course. Dr.
Henry D. Noyes, of New York, has sent the following letter to
Dr. John V. Shoemaker, the secretary of the committee: "I
beg to acknowledge your favor of the 19th ult., informing me
of my appointment as First Vice-President of the Ophthalmo-
logical Section of the Ninih International Medical Congress by
the committee which met at Chicago. This position I can not
accept, because by so doing I should assent to the action of the
American Medical Association, which has thrust into the Inter-
national Medical Congress a controverted subject with which
the Congress has no concern, ;.nd has determined to exclude
from all official position the medical men whose convictions in
this regard it disapproves of. I refuse to admit that the compo-
sition of the International Medical Congress should be in any
way determined by the controverted points of the Code of
Ethics of the American Medical Association. I also refuse to
jcin in treating with neglect or disrespect honorable and emi-
nent physicians who do not accept all the restrictions of that
code about medical consultat'ons. The right of the American
Medical Association to take this course can, I think, be success-
fully challenged, but, for my own decision, it is enough that I
can not concur with it, and that I feel sure that its pur>uance
will prove most hurtful to the Congress, in whose welfare, as
you know, I have taken a deep and active interest. For the
243
courtesy of the committee in tendering me this honor I beg you
to express my thanks."
The British Medical Association.— A correspondent in-
forms us that Dr. H. P. C. Wilson, of Baltimore, has been
elected a member of the association.
Dr. Oliver Wendell Holmes will reach his seventy- sixth
birthday to-day.
The Medical Society of Virginia will hold its annual
meeting at Alleghany Springs on the evening of Tuesday, Sep-
tember 15th. The session promises to be one of unusual in-
terest.
The Mississippi Valley Medical Association will meet at
Evansville, Ind., on Tuesday, Wednesday, and Thursday, Sep-
tember 8th, 9th, and 10th. Railroad and hotel rates will be
reduced for the occa>ion. Full particulars can be obtained of
Dr. A. M. Owen, Evansville, Ind.
The Death of Prof. Berger, of Breslau, who, although
young, was distinguished as a neui o-pathologist, is announced
in the "Revue de medecine."
The Death of Prof. Aeby is also announced by the same
journal. He was well known as an anatomist.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical department,
United States Army, from August 16, 1885, to August 22, 1885:
Wolverton, W. D., Major and Surgeon. Granted leave of ab-
sence for twenty days. (Washington Barracks, D. C.) S. O.
171, Department of the East, August 14, 1885.
Maus, L. M., Captain and Assistant Surgeou. In addition to
his other duties, assigned to duty as attending surgeon of
the Department Rifle Camp. S. O. 83, Department of Da-
kota, August 3, 1885.
Black, C. S., First Lieutenant and Assistant Surgeon. Upon
return of troops F and L, Third Cavalry, to Fort Davis,
Texas, to rejoin his proper station, Fort Clark. Texas. S. O.
98, Department of Texas, August 13, 1885.
McCaw, W. D., First Lieutenant and Assistant Surgeon. Having
reported back at these headquarters from detached service,
ordered to rejoin his proper station, Fort Lyon, Colorado.
S. O. 122, Department of the Missouri, August 17, 1885.
Naval Intelligence.— Official List of Changes in the Medi-
cal Corps of the United States Navy during the two weeks ending
August 22, 1885.
Beyer, H. G., Passed Assistant Surgeon. To attend meeting
of the American Association for Advancement of Sciences,
at Ann Arbor, Michigan, and at conclusion of meeting to
resume duty at the Smithsonian Insrrutiou.
Boyd, John C, Passed Assistant Surgeon. Ordered from Navy
Yard, Washington, D. O, to special duty at Bureau of Medi-
cine and Surgery, Washington, Navy Department.
Drennan, M. O, Surgeon. Assigned to temporary duty at
Annapolis, Md., as member of board for physical examina-
tion of candidates for admission to U. S. Naval Academy.
Lippincott, J. O, Passed Assistant Surgeon. Ordered to Navy
Yard, Washington, D. O, as relief of Passed Assistant Sur-
geon Boyd.
Owens, Thomas, Assistant Surgeon. Relieved from special
duty at Bureau ot Medicine and Surgery, Navy Department,
and waiting orders.
Sayre, J. S., As-istant Snrgeon. Ordered from United States
Receiving-Ship Independence to Naval Hospital, Mare Isl-
and, California.
MINOR PARAGRAPHS.
244
LETTERS TO THE EDITOR.
[N. Y. Med. Joob.,
Simon, Wm. J., Surgeon. Assigned to temporary duty at An-
napolis, Md., as member of board for physical examination
of candidates for admission to U. S. Naval Academy.
Marine-Hospital Service. — Official List of Changes of
Stations and Duties of Medical Officers of the United States
Marine- Hospital Service, for the week ending August 22, 1885.
Bailiiache, P. II., Surgeon. Granted thirty days leave of ab-
sence. August 15, 1885. Chairman of board to examine
candidates for appointment as cadet in the Revenue-Marine
Service. August 19, 1885.
Irwin, Fairfax, Passed Assistant Surgeon. Recorder of board.
August 19, 1885.
Society Meetings for the Coming Week :
Tuesday, September 1st: Elmira, N. Y., Academy of Medicine;
Buffalo Medical and Surgical Association; Ogdensburg,
N. Y., Medical Association; Medical Societies of the Coun-
ties of Franklin and Niagara (Lockport), N. Y. ; Hudson
County, N. J., Medical Society (Jersey City) ; Androscog-
gin County, Me., Medical Association (Lewiston).
Wednesday, September 2d: Medical Society of the County of
Richmond, N. Y. (Stapleton).
Thursday, September 3d: New York Academy of Medicine;
Society of Physicians of the Village of Cauandaigua, N. Y. ;
Obstetrical Society of Philadelphia.
Friday, September J^th: Practitioners' Society of New York
(private).
Saturday, September 5th: Clinical Society of the New York
Post-Graduate Medical School and Hospital; Manhattan
Medical and Surgical Society (private); Miller's River,
Mais., Medical Society.
f filers to % m'xiox.
THE DISINFECTION OF RAGS.
Baltimore, August 23, 1885.
To the Editor of the Kew York Medical Journal :
Sir: I am glad to learn from the letter of Mr. Augustine
Smith, published in the "New York Medical Journal" of Au-
gust 8th, that the paper-makers do not object to the disinfec-
tion of rags from infected ports, and are even willing, "out of
deference to public opinion," to have their importation from
such ports entirely prohibited.
I for one should not be inclined to insist upon the disinfec-
tion of rags shipped from healthy ports if we could he sure that
they had not been collected in infected localities. Here is the
great difficulty with which health officers have to contend. It
is evidently impossible in many instances to ascertain exactly
where the rags have been collected. For example, if an Eng
lish ship, sailing from Southampton or Liverpool, should bring
a cargo of rags to New York, would any one suspect, the possi-
bility that these rags might have been collected in Spain ? Yet
this is not simply a possibility, but, seems to be quite a probable
event in view of the recent order of the Local Government
Board, dated June 23, 1885. I quote from this order Articles
II and III:
" Article II. From and after the date of this order, and
until the first day of November, 1885, no rags from Spain shall
be delivered overside, except for the purpose of export (italics are
mine), nor landed in any port or place in England or Wales."
"Art. II T. If any rags are delivered overside or landed in
contravention of this order, they shall, unless forthwith ex-
ported, be destroyed by the person having control over the
same, with such precautions as may be directed by the medical
officer of health of the sanitary authority within whose jurisdic-
tion or district the same may be found."
Comment is scarcely necessary ; evidently a merchant re-
ceiving a cargo of rags from Spain has but one way to save his
property from destruction, under the order of the Local Govern-
ment Board, viz., to "forthwith" export the rags to the United
States, or some other country willing to receive them.
Those who have opposed the disinfection of rags have^
claimed that there is no case on record in which cholera has
been transmitted by means of rags. Even if this were true, the
evidence that is on record with reference to the communication
of the disease to laundresses by means of the soiled linen of the
sick would be a sufficient reason for excluding rags from in-
fected ports, unless disinfected in a satisfactory manner. But
there is a case on record which seems to be well authenticated.
I quote from a letter received a few days since from Dr. Son-
deregger, president of the Swiss Aerzte Commission, and dele-
gate from Switzerland to the International Sanitary Conference
of Rome :
'• The fact relating to rags was observed and described by
Prof. B iermer (living now in Breslau as Professor of Practical
Medicine), and by Dr. Zehnder, vice-director of the board of
health (Sanitatsrath), who were both most active at the time of
cholera at Zurich in 1867: July, August, September, October,
number of patients 684; number of deaths 65-9 per cent.
" Kriegstetten is a small village in the canton of Solothurm, at
eighty to one hundred kilometres distance from Zurich, and not
connected with this town either by water (lake, river, marsh)
or by trade and industrial commerce. There is a paper-mill at
Kriegstetteu, and a work-woman, who had to tear the rags, was
suddenly taken with cholera and died the following day. The
following days sixteen more work-women (all occupied in tear-
ing the rags) were taken sick : of these, eleven died. A careful
examination showed that all of these rags went from Zurich
and from cholera-houses; therefore the whole mass of rags was
disinfected by boiling. After this no case of cholera occurred.
The large establishment of the paper-mill, as well as the village,
remained free. I mentioned the fact in a little address to the
Swiss people, which I have the honor to send you,* and nobody
doubted the fact or made any opposition. The fact was known
everywhere in Switzerland."
George M. Sternberg.
THE INTERNATIONAL MEDICAL CONGRESS.
Albany, August 21, 1885.
To the Editor of the Xew York Medical Journal:
Sir: Soon after the meeting at Chicago of the new com--
mittee to rearrange the International Medical Congress I saw
my name mentioned in a reported list of proposed officers of
sections. As this was not an authenticated publication, I did
not feel warranted in taking action until I should receive the
customary official notification of appointment. Finding, how-
ever, that none of those named in the printed report appear to
have been otherwise notified, and being unwilling to remain in
an attitude of even seeming ambiguity, I beg to say that 1 have
no intention of holding any position in connection with the
proposed scheme. I am, sir,
Faithfully yours,
Alfred Ludlow Carroll, M. D.,
Fellow State Medical Association.
* This " little address " is an admirable sanitary tract, giving prac-
tical directions relating to disinfection, etc. G. M. S.
August 29, 1885.]
PROCEEDINGS
OF SOCIETIES.
245
NEW YORK ACADEMY OF MEDICINE.
Meeting of June 18, 1885.
The President, Dr. A. Jaoobi, in tbe Chair.
The Operation for Lacerated Perinseum.— Dr. H. W.
Mitchell rend a paper in which he described his method of re-
pairing tbe lacerated perineum, which, he said, was essentially
the method practiced about as long ago as 1850 by Dr. Isaac E.
Taylor, and which had been practiced by Dr. Thomas and
others. He thought to repair the perinaeum was a simple pro-
cedure— one which any surgeon of ordinary skill and knowledge
of the parts could carry out. The lacerated parts being held
apart by two assistants, the surgeon introduced his left index-
finger into the rectum, and with curved scissors pared off the
mucous membrane of either side down to the median line, tak-
ing care not to go up too high on the sides, which would be to
leave a pocket between the rectum and vagina after the sutures
had been passed. The parts were now ready for the passage of
sutures. These he introduced by the small sized curved needle,
commencing below, and passing them sufficiently deep to give
a firm support. The number passed was usually three or four.
He used silver wire, threaded directly on the needle, thus dis-
peusing with the ordinary clumsy method of first passing a silk
suture, and by this jerking a wire through. He then passed
some superficial silk sutures and approximated the edges of the
skin. Having made the bowels move freely previous to the
operation, he kept them confined about six days afterward.
Cleanliness was sufficient antiseptic precaution ; out of forty
cases, the histories of all of which he read, carbolic-acid solu-
tion was used in only five, and in the others no so-called anti-
septics were employed. In all of the forty cases there was
union by first intention ; the wires were usually taken out on
the sixth or seventh day ; in a number of the cases a laceration
of the cervix uteri was repaired at the same time. None of the
operations were primary.
Dr. A. C. Post said that, the author's cases having been so
eminently successful, no exception could be taken to either the
discarding of antiseptics or the details of the operation. He
thought, however, there was an advantage in keeping the bow-
els free after the operation, and he thought this plan was now
coming into general practice.
Dr. Malcolm McLean could not understand how the author
had found drawing the silver wire through by means of the silk
loop a disadvantage when all other operators had found the loop
an advantage. He also thought the curved needle had gener-
ally been discarded because it was liable to turn or to break;
the modern method of lifting the parts into line and passing the
straight needle he thought much better. Nor could he under-
stand how it happened that Dr. Mitchell's patients escaped pain
after the operation, which others had always found to be so
troublesome.
Contagious Conjunctivitis. — Dr. Joseph A. Andrews read
a paper on this subject. It will be published in full hereafter.
BROOKLYN PATHOLOGICAL SOCIETY.
Meeting of February 26, 1885.
The President,. Dr. B. F. Westbrook, in the Chair;
Dr. A. H. P. Leuf, Secretary.
Pulmonary Gangrene. — Dr. Eliza M. Mosiier read a paper
giving a history of a case of this sort, with remarks. [See
p. 233.]
Demonstrations of an Easy Method for the Estimation
of Urea and Sugar in the Urine was the title of a paper read
Dr. W. M. Hutchinson.
Caesarean Section. — Dr. Charles Jewett read a paper giv-
ing the history of a case, with remarks. [See p. 231.]
Intra-ocular Melano-sarcoma.— Dr. Arthur Mathewson
related the case of a patient, fifty-nine years old, who had first
been examined by him November 28, 1882, when a large detacht
ment of the retina, in the lower part of the fundus of the right
eye, was discovered with the ophthalmoscope. The vision of
the eye was totally lost in the course of a few months, bu-
there was no pain or inflammatory symptoms till the autumn of
1884, when the other eye became red and painful, with great
increase of tension. The crystalline lens had become opaque so
that nothing of the fundus could be seen. Other means of re-
lief from the torturing pain having failed, the eye was enucle-
ated October 30, 1884, when a large melanotic mass was found
occupying three fourths of the vitreous chamber, and extending
back through the sclera about the optic nerve. Microscopic
examination showed the growth to be a melano-sarcoma. The
point of chief interest in this case was the fact that there was
nothing in the appearance at the first ophthalmoscopic exami-
nation to distinguish it from an ordinary detachment of the
retina from other causes, and nothing to indicate its dangerous
character. The lesson to be drawn from it was, always to be on
the lookout for morbid growths behind the retina as a possible
cause of its detachment, and to enucleate early where there
seemed to be just ground for this suspicion. In this case, as in
others formerly presented by him to the society, sooner or
later some of the abdominal viscera would probably become the
seat of melanotic growths. As yet there was no appearance of
the growth in the orbital tissues.
A Foetus of Five Months and a Half, as was estimated,
was shown by Dr. E. II. Bartley, who said that it had lived
quite thirty-two hours after its birth.
Urethral Stricture, with Complications.— Dr. C. N. D.
Jones read a paper embracing the history of the case, with re-
marks. [Seep. 235.)
Cancer of the Breast. — Dr. George Waokerhagen related
the case of a woman, forty-five years old, who had been mar-
ried twenty-six years and had never been pregnant. She ceased
to menstruate at the age of forty-three. Six months ago she
first noticed a small lump in the left breast. It enlarged very
slowly, and she did not complain of pain until about six days
before the operation; it was then of a burning and shooting
character. The breast was removed on the 10th of January,
together with all the axillary glands, although the latter were
not diseased. Strict antiseptic precautions were observed, and
the patient made a good recovery. Microscopical examination
showed the tumor to be atypical carcinoma, with thick alveolar
walls and small alveoli containing epithelial cdls.
Abdominal Cancer, with Perforation of the Stomach.
Dr. W. C. Bdrke, Jr., of South Norwalk, Conn., read the his-
tory of the case. [The author reserves it for future publication.]
MEDICAL SOCIETY OF THE COUNTY OF KINGS.
Meeting of June 16, 1885.
The President, Dr. J. A. MoCorkle, in the Chair ;
Dr. Z. T. Emery, Secretary.
The Salicylic-Acid Treatment of the Intestinal Catarrh
of Infancy.— Dr. W. A. Northridge read a paper with this
title. [See p. 229.]
246
PROCEEDINGS OF SOCIETIES.
[N. Y. Mrp. Jock.,
Dr. E. II. Bartley. said that he had had some little experi-
ence in the salicylic-acid treatment of the diseases of children.
He had begun this treatment in 1880, taking the suggestion from
a paper read before this society by Dr. Hutchins. Dr. Ilutchins
had used the same treatment recommended by the author of the
paper just read, and had reported very flattering results. He,
however, recommended it only in certain cases — if the speaker's
memory served him, in cases of watery diarrhoea, in cholera
infantum, so called; and in those cases he obtained very excel-
lent results. The speaker had begun the use of it, hoping to
find something that would check the large number of cases that
he was called upon to treat, and he must say that he had been
very much disappointed in the drug. Since then he had used
it more or less every summer, but he selected the cases. lie
thought it a valuable remedy, but he would not laud it so highly
as the author of the paper had. In the histories that had been
reported we must consider one thing which was very favorable
to the drug, and that was that these patients had been sent from
an over-heated, over-crowded, and filthy tenement-house re-
gion, as a rule. They were the children of poor people who
could not afford even fresh air at home, and they were sent to
the island for the purpose of securing fresh air. All of them,
with one exception, if he remembered rightly, were put upon
the salicylic treatment on reaching the island. We should natu-
rally expect an improvement, with any treatment or no treat-
ment, in children taken from a heated, over-crowded part of
the city and brought to Coney Island, where they got a free
supply of fresh cool air. That, of course, was favorable to the
drug, and made the author's statistics look a little brighter than
they would look if he had had to treat children in Front, Wa-
ter, Hicks, Columbia, or Van Brunt street. Histories from
those streets would show a much smaller number of cures.
Still, as he had said before, with selected cases there was a great
deal of efficiency in salicylic acid. These selected cases were
those of true fermentative diarrhoea — a point that he had laid
some stress upon in a paper read before the society a year ago.
There were some cases that began as a true fermentation in the
undigested food of the lower canal, giving rise to intestinal
catarrh, afterward extending either to the stomach, producing
gastro-enteric catarrh, or extending downward and becoming a
colitis. In such cases salicylic acid would act beneficially. He
was not sure but it would act fully as well, if not better, if ad-
ministered in the form of salicylic acid instead of this form of
salicylate of calcium.
The author bad made the remark that the effect was due
principally to the salicylic acid. If that was true, of course it
would be quite as well to use salicylic acid. A part of the effect
was due to the anti-fermentative effect of salicylic acid, and
part to the astringent effect of salicylate of calcium. He thought
it was a little unfortunate that the author had not attempted to
give us a little more of his impression as to whether these cases
were of this fermentative character. Of course, his means of
observation in that respect had not been what they would be
in treating a case from its inception. He took the case well
established, ami did Eot know much of the previous hi.-tory, ex-
cept from a very brief statement sent with the patient ; but the
speaker thought it was stretching the thing a little, to say the
least, to recommend the method as a wholesale treatment in all
cases of summer diarrhoea. Instead of salicylic acid he had
found benzoate of sodium or of 'ammonium to be equally
efficient. To check the green stools, accompanied by undi-
gested food and the free fatty acids, he had found the ben-
zoate of sodium or benzoate of ammonium, in doses of from
one to two grains, to answer the purpose very well. We all
knew the benefit of calomel in these cases. It prevented
the secondary fermentation, and had a very southing effect
upon the mucous membrane. The effect upon the nervous
system was greater, perhaps, from calomel than from salicylic
acid.
In regard to the use of opium, he thought he had had the
best success with it in the treatment of watery diarrhoeas; but
in nearly all such cases, or in a great many, he had used one of
the anti-fermentatives, and had settled down upon the ben-
zoates.
Dr. Walter B. Cuase said that, without questioning the
accuracy of the author's observations regarding the cases which
were under treatment at the Sea-side Home, it seemed to him
that, as had been suggested by the last speaker, the value of any
given course of treatment of a case of entero-colitis or allied
summer diseases of children would be determined, not princi-
pally by the effect of treatment away from home, but by the
effect of treatment at home ; and so the value of statistics which
were made at the sea-side, away from home, was somewhat un-
certain, because we were unable to estimate the value of the
hygienic surroundings and the change of atmosphere. This was
a very large question to discuss, and he did not purpose to occupy
more than a moment. He was coming to believe that, apart
from hygienic surroundings, very much depended upon whether
these little ones who were fed artificially were properly fed. He
believed it was the common experience that at home, or at the
sea-side, or in the mountains, the question of digestion, both
gastric and intestinal, was the principal factor in the safety of
the patient and the time of recovery. No doubt one great
trouble in the treatment of these cases had been due to the fact
that these little ones had been overfed, which added to the de-
pressing effect of heat and of fermentative action in the alimen-
tary canal. The feeding in many cases had been of an improper
kind and at improper intervals. If these children could be fed
[ess, and given some fluid which contained very little nourish-
ment, like barley-water or rice-water, the chances for recovery
would be vastly increased. He had had some experience in the
use of pancreatic extract in the preparation of milk for arti-
ficially fed infants, and was very much interested in it. While
he was not prepared to formulate the result of his experience,
he believed that, if we could prepare milk in such a manner
that when it was acted upon by the juices of the stomach there
should be very small coagula or no coagula, by previously di-
gesting the casein, the further process of digestion might go on
with safety.
Dr. H. N. Read said that he had had some experience with
the treatment described by Dr. Northridge. Dr. Bartley and
he had treated a large number of cases of diarrhoea on the plan
recommended by Dr. Ilutchins some jears ago, which was sub-
stantially that given by Dr. Northridge, by using a mixture of
salicylic acid and chalk. His experience with the remedy coin-
cided with Dr. Bartley's. It was quite useful in some c:ises, e.g.,
fermentative diarrhoeas, but not at all superior to, or indeed the
equal, he thought, of other remedies. The value of the results
of the cases mentioned in the report was very much lessened,
he thought, by want of comparison and classification. Cases of
diarrhoea in infants treated by salicylic acid and chalk in a sea-side
sanitarium, with good air and food and wholesome surround-
ings, and the same cases treated by the same thing in the hot,
dirty tenements of the city, would give very different results.
Under the former surroundings almost any treatment would
give favorable results, while under the latter few plans of treat-
ment would avail. The author had fouud this remedy equally
efficacious in entero-colitis as in the simple diarrhoeas. The
first case of entero-colitis mentioned in the paper exhibited, if
he remembered aright, neither fever nor vomiting, nor was any
mention made of bloody stools. It would be extremely interest-
ing to know how the diagnosis of entero-colitis was made under
August 29, 1885.]
REPORTS ON THE PROGRESS OF MEDICINE.
247
these circumstances. Entero-colitis, being an acute inflamma-
tory affection of the bowel, was necessarily attended by fever,
vomiting, and almost as invariably by bloody and slimy stools.
It differed as much from simple diarrhoea as pneumonia did
from bronchitis. Its pathology and treatment were essentially
different from those of the simple catarrhal diarrhoeas. It
seemed to him, therefore, that the author claimed too much for
the remedy he advocated. While it was useful, undoubtedly, in
the treatment of simple diarrhoea, it had no advantages over
other remedies.
Dr. Topiiam said that he could hardly agree with the author
as to the use of salicylic acid in the treatment of these diseases.
He thought that, instead of their being produced by a germ, it
was by the action of undigested food producing irritation. We
all knew that this summer diarrhoea was essentially a heat dis-
ease, and, if we kept the little ones cool and dieted them prop-
erly, they would need no other treatment. He would rather
hesitate to put three grains of salicylic acid into a child's stom-
ach when lie had it at the sea-side with plenty of fresh air and
full control of its diet.
Rhachitis. — Dr. Henry N. Read read a paper with this
title. [See p. 225.]
Dr. Bartlet said that Dr. Read had spoken of one or two
theories in regard to aetiology. Whatever the explanation was,
it certainly was due to some form of malnutrition or defective
nutrition ; and in tracing back the histories of a number of
cases he had about come to the conclusion that it was very often
due to a long-continued gastro- enteric catarrh. He had risen
more especially to call attention to one element in the produc-
tion of this disease. A man was expected always to speak on
his hobby, if he had one, and not go very far outside of it. He
was going to speak upon his hobby, and that was milk. He
had come to the conclusion that a large number of the cases of
gastro-enteric catarrh were originated and kept up by unsuita-
ble milk. He had recently tried an experiment which was very
suggestive. It was this: Having visited a farm out in the coun-
try, and selected one that he knew was as good a farm as could
be made on Long Island, he requested the man to send him
milk for the Sheltering Arms Nursery in this city. He was to
mark a can "afternoon's milk," so that it would be known
when it reached the city. This was taken to the depot, and five
or six quarts, whatever was necessary for their use, were to be
taken out, placed in a small pail, and delivered at once at the
Nursery ; so that in the morning, at seven or eight o'clock, the
milk of the previous afternoon was delivered at the Nursery
without any churning except what it got on the train. The
child ren, small hand-fed babies, were put upon the use of this
milk. He noticed immediately an improved condition in all of
them, and children that had been dyiug before, in spite of pep-
togenic powder and everything else, now began to thrive; and
he was satisfied that the trouble that led indirectly or finally to
the development of rhachitis was due to" improper food and an
improper milk. He had come to the practice of prescribing
milk for babies as much as medicine. He wanted to know
who put up the medicines, and he wanted to know who served
the milk. Of course, he had the opportunity of knowing better
than most physicians of the good milk-dealers and the poor
ones. He could not advertise anybody here ; he could only say
in general terms that it was always safer to recommend coun-
try milk — not somebody's "farm milk," who brought it from
his own cows, because those "farms" were, as a rule, little
hovels in which as many cows were kept as could endure the
place. It was better to take country milk, and take it directly
from one of the large dairies. And in this regard he wished
strongly to advise every physician to test the milk himself occa-
sionally. An ordinary test-tube would answer for a cream-
gauge; and by means of an ordinary urinometer the specific
gravity could be determined. In regard to the amount of cream
thrown up, it should not be less than ten or twelve per cent-
He would not allow a delicate baby to take a milk that threw
up less than twelve per cent. There were milks that came di-
rectly from the country that did not throw up that, but he
would not allow them to be used. The specific gravity of the
milk should not be less than 1-030 nor above l-035, as that in-
dicated thickening. The ordinary milk in its transportation
received a great deal of churning, and was sometimes kept four
or five days before the baby got it. If it was examined under
the microscope, little lumps of butter would be found. The
field between the fat globules would have a fine granular ap-
pearance. Although it was not sour, it was on the point of
souring, and the minute it got into a child's stomach it would
be apt to form large curds.
Eclampsia in Early Life was the title of a paper read by
Dr. Joseph Healt. [See p. 228.]
gqjorfs on % fjrooress of HUbrchte.
ANATOMY AND PHYSIOLOGY.
By GR^ME M. HAMMOND, M. D.
Distribution of Anaesthesia in Cases of Disease of the Branches
and of the Roots of the Brachial Plexus. — Dr. James Ross (" Brain,"
April, 1 884), after making a very exhaustive study of a large number
of cases in which the functions of the sensory nerves of the brachial
plexus had been destroyed either by disease or by the knife, arrives at
the following conclusions : 1. That one of the principal nerve-trunks of
the brachial plexus may be completely divided without giving rise to
complete anaesthesia in any part of the area of distribution of the sen-
sory branches of the nerve, and that, when complete anaesthesia does
occur, the portion of skin affected is very limited, and even the area of
skin affected is usually much less than that of the district correspond-
ing to the anatomical distribution of the nerve.
2. That, as a general rule, the anaesthesia caused by division of one
or more cutaneous nerves tends to become progressively less in degree
and extent with the lapse of time. From this it follows that in division
of one or more cutaneous nerves the area of normal sensibility tends to
encroach upon the anaesthetic district, so that when one nerve (say the
radial) is divided, its area of distribution, when judged by the extent of
the anaesthesia, appears to be very small, while, when it is the only one
of the three principal nerves of the hand that is spared, its area of dis-
tribution, as judged by the extent of the area of normal sensibility, ap-
pears to be unusually large.
3. That the extent, degree, and even localization of the anaesthesia
caused by the division of any nerve, differ greatly in different cases,
without our being able to discover anything in the injury to the nerve
or in the external circumstances of the patient which would account
for these differences.
4. That the descriptions given by Kraus and by Henle of the ana-
tomical distribution of the digital branches, and especially those derived
from the median nerve, correspond more accurately with the results of
pathological observations than those usually given in English anatomi-
cal works.
On the Connection between Physiological Action and Chemical
Constitution. — In relation to this subject Dr. J. Blake ("Journal of
Physiology," April, 1884) points out that among the salts of the metal-
lic elements the intensity of their physiological action is connected with
the atomic weight of the elements, so that, when the elements are ar-
ranged in isomorphous groups, the action of substances in the same
isomorphous group is a function of the atomic weight ; the greater the
atomic weight, the smaller the quantity required to produce the same
physiological action. Dr. Blake has tabulated a list of substances
24:8
REPORTS ON THE PROGRESS OE MEDICINE.
(N. T. Mbd. Jour.,
whose physiological action has been investigated, arranged in isomor-
phous groups, together with their atomic weight. If, in the first or
soda group, salts of any of the elements contained therein are injected
into the veins in a sufficiently concentrated state to give rise to any
well-marked physiological reaction, they kill by arresting the passage
of the blood through the lungs, apparently by causing contraction of
the pulmonary arteries. When the solution is strong enough, this is
so complete that the circulation is immediately arrested and the animal
dies, the respiration being stopped by the great venous congestion
caused by the blood not escaping from the right side of the heart.
Even when injected into the arteries, these substances kill by their ac-
tion on the lungs, although the quantity is much greater than when
njected into the veins.
In the second, or magnesia group, the most marked physiological
action of the salts of these elements, when introduced directly into the
veins in sufficient quantities, is to suddenly arrest the action of the
heart. This takes place in about ten seconds after the salt has been
injected. When injected into the arteries they generally arrest respira-
tion before reaching the heart. Even in small quantities their effect
on the nervous system is well marked. They give rise to a state re-
sembling catalepsy.
When the salts of the third, or baryta group, are injected in suffi-
cient quantities into the veins, they destroy the irritability of the heart,
its pulsation being arrested in diastole. When injected into the arteries,
the heart's action is affected in three or four seconds. No appreciable
effect is produced on the nervous system, but the most marked results
are noticed in their action on the voluntary muscles. With the salts of
lime this is shown by a thrill running through the whole of the volun-
tary muscles, commencing soon after death, and lasting three or four
minutes. With the salts of strontia and baryta these movements are
much stronger, sufficiently so to move the body half an hour after
death.
In the fourth, or aluminum, group the salts of beryllium, alumina,
iron, yttria, and cerium have been experimented with. The physio-
logical action of these salts is on the vaso-motor and respiratory cen-
ters and on the intrinsic nerves of the heart. Injected into the veins,
these salts produce an immediate contraction of the pulmonary arteries.
When injected into the arteries, inhibition of the heart's action follows
from stimulation of the vagus center.
The salts of the fifth, or platinum group, when injected into the
veins, act directly on the intrinsic nerves of the heart, slowing its action
with vagus pulsation, the arterial pressure being diminished. When
injected into the arteries, the vagus center is immediately affected, the
action of the heart being slowed in two or three seconds. The salts of
this group retard or render imperfect the coagulation of the blood.
In the sixth group the salts of thoria and cerous oxide have been
experimented with. They agree with the alumina group in acting prin-
cipally on the vagus and vaso-motor centers.
The last of the metallic elements, the action of whose salts has
been investigated, is lead. When introduced into the blood, they act
similarly to the soda salts in causing contraction of the arteries and the
secretion of serum in the bronchial tubes, and an analogous action to
the baryta salts, whereby muscular movements continue many minutes
after death. They also give rise to contraction of the systemic arteries.
The seventh group contains phosphorus, arsenic, and antimony,
and, when introduced directly into the blood, are not followed by any
well-marked physiological effects. In poisonous doses they kill either
by paralyzing the heart or by their action on the mucous membrane of
the lungs, a serous secretion being poured out which prevents the aera-
tion of the blood. The whole of the mucous membrane of the alimen-
tary canal is also acted on.
In the eighth group the salts of sulphur and selenium, when intro-
duced into the arteries, arrest respiration by their action on the nervous
system. They do not affect the systemic arteries, but cause secretion
from the lung capillaries into the air-passages.
The ninth group contains the elements chlorine, bromine, and iodine.
They all act on the vaso-motor and respiratory centers and keep up the
irritability of the heart.
Hemisection of the Spinal Cord. — " The most careful experiments
on the lower animals," says Ferrier (" Brain," April, 1884), " such as
those of Ludwig and Woroschiloff, always leave room for doubt
whether the reactions which result from the application of sensory
stimuli to parts below the experimental lesion are to be regarded as
signs of sensation proper, or merely of reflex action more or les3 gen-
eral. On questions involving subjectivity, the most satisfactory evi-
dence would be furnished by observations in man, but we rarely, if ever,
meet with spinal lesions so exactly limited as to be made available for
this purpose."
With the view of determining the effects of strictly unilateral divis-
ion of the spinal cord in an animal as nearly human as possible, Fer-
rier made the following experiment on a monkey :
The. animal was chloroformed, and, under stringent antiseptic sur-
gical precautions, the cord was exposed and the left half divided mid-
way between the seventh and eighth dorsal nerves. For eighteen days
the animal remained in good health, but at the expiration of that time
died suddenly. Examination revealed an extensive clot pressing on the
anterior face of the pons and medulla oblongata.
The wound in the dorsal region was more or less gaping, but per-
fectly free from pus. The pia mater was thickened, but the cord, with
the exception of the lesion described below, was entirely free from in-
jury or inflammatory softening.
The results of the lesion were as follows :
Mobility. — On the side of the lesion (left) the leg was absolutely
paralyzed as to motion, and was dragged when the animal moved about
the cage with the aid of the hand and the right leg.
The temperature of the left leg was, during the first two days, much
higher than that of the right. After the fourth day no difference in
temperature was noticeable.
The patella-tendon reaction was at first greatly impaired or entirely
abolished. Before death, however, the left patella reaction was more
distinct than the right.
Sensibility. — The slightest touch or ruffling the hair of the left foot,
flank, or left side of the tail, invariably attracted the animal's attention.
A prick with a pin, a pinch, or a touch with a heated wire, caused it to
rub the part or angrily try to seize and bite the offending cause. Hy-
peresthesia of the left leg was not shown on the opposite side (right).
Mobility. — The right leg was freely moved volitionally in all direc-
tions. The animal could grip with its right foot with considerable
vigor, and did so, as well as with its hands, when it wanted to free itself
when held prisoner. This, however, was only true when vision was
free and no impediment was offered to the intended movement of the
right leg. The manifest difference between the use of the right leg,
with and without vision, clearly indicated the abolition of the sense of
muscular contraction, and inability to appreciate the position assumed
by the leg, except with the aid of vision.
Sensibility. — In addition to the abolition of the so-called muscular
sense, there was total absence of any signs of perception of contact.
Pinching, pricking, or the application of heat failed to produce any sen.
sation. There was thus total anaesthesia and analgesia of the right leg,
and this extended to the right flank and right side of the tail.
The power of evacuating the contents of the bladder and rectum
was not perceptibly affected.
We have thus in this case complete motor paralysis, with retention
of sensibility, on the side of the lesion, and complete anaesthesia and
analgesia, with retention of mobility, on the side opposite the lesion.
The Lesion. — No softening existed. The left anterior column im-
mediately bordering the anterior fissure (the anterior median column), a
small portion of the anterior root zone, and a portion of the left poste-
rior column immediately bordering the posterior fissure, were undivided.
The whole of the columns on the left side of the cord, with these excep-
tions, were divided.
Microscopical investigation showed ascending degeneration, charac-
terized by atrophy of the axis cylinders without any increase in connec-
tive tissue, in the left columns of Burdach, and in the direct cerebellar
tract both above and below the lesion.
Below the lesion there was disappearance of axis cylinders in the
postero-lateral column of the left side corresponding to the area of
the crossed pyramidal tract. No degeneration was detected in any of
the other columns.
The Relation of the Nervous System to the Temperature of the
August 29, 1885.]
NEW INVENTIONS.— MISCELLANY.
249
Body. — Dr. Isaac Ott (" Journal of Nervous and Mental Diseases,"
April, 1884) has lately made some interesting experiments in this direc-
tion. His plan was to make transverse sections of the brain from be-
fore backward. The apparatus used was d'Arsonval's calorimeter and
Voit's respiration apparatus. The experiments were made on rabbits
and cats. The method pursued was as follows : The animal was placed
in the calorimeter and the change in the rectal thermometer noted, as
well as the amount of air aspirated from the calorimeter. After an
hour or two the animal was removed, etherized, and a transverse sec-
tion of the brain was made. When it had recovered from the ether it
was again placed in the calorimeter, and the same changes as hereto-
fore noted. The skull was broken up by a bone forceps and the
"seeker" introduced, the section being made by its blunt edge. The
small seeker penetrated the cortex with but little injury to it, and, when
it reached the base of the brain, was drawn transversely so as to divide
the parts without injuring the cortex of either side. In the first ex-
periment the olfactory bulbs were divided without being followed by
any rise in temperature. In eight experiments in which a transverse
section was made behind the corpora striata, the temperature rose in
seven of them from 1° to 4^°, while in one the temperature fell f
probably from shock. Three experiments, in which the transverse sec
tion was made through the middle of the corpora striata, were per-
formed. In one there was a rise of 7°, in another a rise of and
in the third a fall of 6|°. Observation made on the day following a
section behind the corpora striata showed that the rise in temperature
was not wholly temporary. All these experiments, Dr. Ott concludes,
lead up to the belief that in the vicinity of the corpora striata there
are centers which have a relation to the temperature of the body.
On Rhythmic Contractions of the Capillaries in Man. — Dr. T. Lau-
der Brunton ("Journal of Physiology," April, 1884) claims that, although
rhythmical contraction and dilatation of the small blood-vessels, independ-
ently of the action of the heart, have been observed in the lower animals,
they have not hitherto been described in man. The cases in which rhyth
mical pulsation, independent of the heart and of the respiratory move-
ments, was observed were cases of marked aortic regurgitation. When
the aortic valves are incompetent, the blood flows back into the heart dur-
ing the diastole, leaving the pressure in the arterial system low. The
heart thus receives during diastole blood from two sources — from the
pulmonary veins and from the aorta — so that at the next systole a very
large wave is forcibly driven into the relaxed aortic system. The alter-
nate distension and relaxation of the small arteries render pulsation in
them much more readily observed than in ordinary cases. The method
of observing it is this : The finger-nail should be drawn once or twice
up and down the middle of the forehead ; a red streak is left, which
will sometimes remain for many minutes. This streak undergoes vari-
ations of width and brightness which are very evident to the eye, and
some of which coincide with the beats of the heart. In addition to
this, a second rhythm of contraction and dilatation may be observed cor-
responding to the respiratory movements, and the rate of which is
about eighteen a minute. But, in addition to these two rhythms, Dr.
Brunton observed a third, which he is inclined to regard as due to inde-
pendent contraction of the minute vessels. It is difficult to ascertain
precisely the rate of this capillary rhythm, but, from a number of ex-
periments, it may be said that it usually occurs approximately at the
rate of one in twenty seconds. It is probable, however, that this rate
is subject to numerous variations.
Ueto Jfnbmtions, etc.
AN INTR A-V AG IN AL CUP SYRINGE.
Bv E. P. Eraser, M. D.,
PliOFKSSOR OF GYNAECOLOGY, MEDICAL DEPARTMENT OF THE WILLAMETTE
UNIVERSITY, PORTLAND, OREGON.
The proper administration of therapeutic vaginal injections in the
dorsal recumbent position, with hips elevated, is almost impossible,
owing to the discomfort, annoyance, and expense attending the use of
the various contrivances for receiving the injection fluid as it leaves the
vagina. These are entirely overcome by the simple instrument shown
in the accompanying woodcut.
The instrument consists of a cup made of soft rubber with a flexible
ring around the top. Through the bottom of the cup pass the afferent
tube (D), with hard rubber nozzle,
and the efferent tube (C), to which
is attached a waste-pipe two feet
and a half long, for conveying the
fluid into a receptacle under the
bed or table. These tubes are sup-
plied with patent stop-cocks (A
and B). The nozzle (E) may be re-
moved from the cup when desired.
The cup is readily introduced into
the vagina by compressing the flexi-
ble ring, which easily passes the
sphincter muscles, and, expanding,
produces sufficient pressure on the
vaginal walls to prevent the escape
of the fluid except through the ef-
ferent tube.
The nozzle of any style of syr-
inge may be inserted into the affe-
rent tube, and any quantity of water
may be injected with perfect comfort
to the patient. The patient lying
on the back with hips slightly ele-
vated, the fluid dilates the upper por-
tion of the vagina and comes in con-
tact with the entire surface, while
the more sensitive portions of the vagina, vulva, and perinaeum are
completely protected in case very hot water is used.
In applying to the vagina or cervix glycerin, or glycerole of tannin,
or any fluid application, the nozzle being removed, close the stop-cock B
in the efferent tube, remove the waste-pipe, inject the application, close
the stop-cock A, and leave the instrument in situ. Instruct the patient
to allow the fluid to escape at a specified time and to remove the instru-
ment, or allow it to remain in the vagina as a temporary support to the
uterus, thus doing away with cotton and oakum tampons. Many ways
will suggest themselves to the physician in which this simple instru-
ment may be made useful. I have derived much satisfaction from its
use, as with it vaginal injections and medicinal applications to the
vagina and uterus may be properly administered with the greatest
facility. It is gladly given to the profession, believing that it only
needs to be tried to be appreciated.
These instruments are manufactured by George Tiemann & Co.,
New York City.
i st je 1 1 a n d .
The International Medical Congress. — The " Medical News," after
referring to the statement made in the " Journal of the American Medi-
cal Association " in reference to the alleged resignation of Dr. John H.
Packard, as Secretary-General of the Congress, says :
" We are just informed by Dr. Packard that the above statement,
so far as it concerns him, is absolutely false and without foundation,
ind that he has written to the editor of the ' Journal of the Associa-
tion ' a letter for publication to that effect. While the new committee
has never had any claim to public support, we yet regret that, to stimu-
late its waning strength, it should still further estrange public confi-
dence by again resorting to the method of willful misrepresentation to
which it owed its birth.
" Under the circumstances it is necessary for the ' Journal of the
Association ' to present the proof of the correctness of its statement
concerning the intentions of other gentlemen before the profession can
give to it unqualified belief."
250
MISCELLANY.
[N. Y. Mkd. Joob,,
The " Journal of the American Medical Association," in an editorial
entitled " More Signs of Progress," says :
"In regard to the rules for regulating the conditions of membership
and the working of the Congress, it is well known that all the rules
relating to the latter were adopted by the new committee without
change. The only change of importance proposed was in Rule 1, which
related to the terms of membership. The change in this rule proposed
by the committee was not satisfactory, and it is still open for further
consideration and adjustment at the coming meeting of the committee
on the 3d of September. In our issue of August 8th we gave two
propositions that had been suggested for regulating the American Mem-
bership of the Congress, both of which were amply liberal — the one
retaining the representative principle and applying it to all the national
special organizations, as well as to the National Association and the
State and local societies in affiliation therewith ; the other opening the
door of the Congress, so far as its scientific proceedings and interests
are concerned, to all members of the regular profession who might
choose to register and take their tickets of admission. If either of
these propositions is satisfactory, let the ' News ' say so. Or, if it
will be more satisfactory to all parties, and will be accepted as a basis
of adjustment to have the Rule 1 read simply as follows : ' The Con-
gress shall be composed of members of the regular medical profession
who shall have inscribed their names on the register, and taken out
their tickets of admission,' thus making the terms of membership alike
to all, American and foreign, let the ' News ' and its friends indicate
this, and the proposition will receive a fair consideration. They can
not longer maintain their dog-in-the-manger policy on purely personal
considerations without passing into history as persistent obstructionists,
who place tjieir personal prejudices above the honor and welfare of the
profession to which they belong.
" The 3d of September is near at hand. If those members of the
profession who so abruptly abandoned the honorable and responsible
positions to which they had been assigned wish to retain those posi-
tions, and aid in maintaining the honor and interests of the profession
of their country, let them move in that direction soon, or their places
will be filled by others equally eminent, and the good work will move
on without them. To talk of restoring the Original Committee of eight
appointed by the association at Washington, and enlarged by its own
action, is simply childish. It is perfectly well known that the original
committee appointed at Washington is now an integral part of the pres-
ent Committee of Arrangements, and has no existence in any other
capacity or connection. The enlargement of the original committee by
the addition of a representative from each State, and from the Medical
Corps of the Army and Navy, instead of a less number selected from a
few cities, neither lessens the efficiency nor detracts from the dignity
of the committee, as simply a Committee of Arrangements. And such
committee will proceed with its work in a true conservative liberal
spirit, and will complete the preliminary organization of the Ninth In-
ternational Congress on as liberal a basis and under the official leader-
ship of as eminent and learned men as the profession in America con-
tains."
The " Lancet " says :
"We are glad to gather from our latest information from the United
States that the prospects of the International Medical Congress meet-
ing have improved. It would be strange indeed if such a project in
such a country could fail of a successful issue. The organization of
the profession there may be somewhat different from what it is in older
countries, and there may be ideas of professional freedom which ex-
ceed ours. There may even be questions of a personal character in-
volved in the arrangements to be made ; but that the arrangements will
be great, and conceived in a magnanimous spirit, and worthy of the
profession of a great country, may, we trust, be taken as already se-
cured. One guarantee of this hopeful view being realized is to be
found in the nomination of Dr. Flint as president of the Conference.
Dr. Flint is so well known among us, not only by his works, but by his
genial and dignified presence, that the English profession will need no
other proof of the oneness of the profession in both countries, both in
its spirit and its practice, than the selection by the American Medical
Association of this distinguished physician for the chair of the Con-
gress. It will be the same in other European countries. Dr. Flint
has not hesitated to take long voyages in promotion of the internationa
co-operation of the profession. He was as active at Copenhagen as in
London, and we doubt not that the European response to the American
invitation will be wide and hearty. The little differences which have
arisen in America are such as the near approach of the Conference will
dispel or resolve. Some of them are differences which will keep, and
which can be postponed till after the Congress. The Congress itself
will swallow many of them up, and give an overwhelming exhibition of
the unity of the profession, such as will best at once answer and convert
those who would break it up into sections and cliques, or liberate any
of its members from those great traditions which have been the distinc-
tion of the profession from the time of Hippocrates downward.
" There are, indeed, powerful attractions to draw members of the
profession over to Washington in 1887. The road is not an untrodden
one. Many of our brethren have already crossed the water, and they
bring back but one report of the greatness of the land, and the hos-
pitality and kindness of its people, and especially of our medical breth-
ren. Besides this, we need not remind our readers of the fact that
medical art and science are in a most active state across the Atlantic.
The Americans set us an excellent example year after year of disregard-
ing the sea and its sickness in search of knowledge, and to acquire the
last hints of Europe in art or science. They come so freely that we are
apt to think they are only learners, and not teachers; but no mistake
could be greater. They are profoundly influencing both surgery and
medicine, and our own foremost leaders would be the first to admit
their indebtedness to American physicians and surgeons in respect of
details and of boldness in the improvement of instruments, in the
great operations of surgery, in the addition of new medicines, and of
enterprise in the whole field of pathology and therapeutics."
The " Medical Times and Gazette " says :
" The present medical situation in the United States has received
less attention on this side the water than it deserves. But we may
assure our American readers that all here who have mastered the ques-
tion sympathize most deeply with them in the trouble that has befallen
them. A disagreement like the present is, for many reasons, taken
more to heart by our American kinsmen than it would be in England,
assuming for the moment such a schism to be possible here. The
American temperament differs perceptibly from ours. It is less insular
and phlegmatic, more sensitive, we fancy, to the opinion of other coun-
tries, more concerned to make a good appearance before the world.
Then the position of the medical profession in America is somewhat
different from that which it holds in this country. Here we take a
comparatively inferior place in the social hierarchy; we are over-
shadowed by estates and professions of higher importance and prestige
in the nation's estimate. Our organization too is more oligarchical ;
there is more reverence among us for authority. Our leaders do lead,
and if they are unanimous in any undertaking, as in the case of the
London Congress, being able to count on the support of royalty, and
the city, and South Kensington, and other depositories of power, they
can afford to be indifferent to the support of the mere privates in their
army. Even if the editor of the 1 British Medical Journal' and all his
council had made up their minds to control the Loudon Congress or to
wreck it, they would only have made themselves ridiculous. But in the
United States the position of the profession is entirely-different. There
is nothing to overshadow it there. It holds a position as important and
honorable in the State as that of any other calling ; so that an Interna-
tional Medical Congress in America may be expected to enjoy a higher
dignity from a national point of view than it can claim in older coun-
tries ; but, at the same time, it must depend far more largely for its
ceremonial success on the harmonious co-operation of the medical pro-
fession itself. Now, in the United States, the organization of the pro-
fession is purely democratic ; there is no common link like that of our
royal colleges, no recognized headship like that of our president of the
College of Physicians, or our president of the College of Surgeons.
According to the very political theory on which the State is founded,
every man has as good a right to lead as any other, if he can only get
that right admitted by his fellows, and for that purpose one vote is as
good as another. Distinction in science and reputation abroad supply
no reason to a practitioner in Texas or Colorado why he should follow
a Wendell Holmes or a Weir Mitchell in preference to a Shoemaker or
August 29, 1885.]
MISCELLANY.
251
a Beverley Cole. Hence a revolt of the ' rump ' in the United States
threatens to prove a much more disastrous affair than it would be in
England, and hence we especially ask our readers' sympathy for those
well and widely known American practitioners whose title to lead their
profession is admitted everywhere except in the ruder and remoter
States of their own country.
" We have had an opportunity of seeing several letters from distin-
guished American practitioners, and they all concur in expressing the
most bitter grief and disappointment at the pass to which their profes-
sion has been brought. In these letters we have met with scarcely one
word of anger against the dissidents who have rudely torn up the first
programme of the Congress. Indeed, if we may say so without imperti-
nence, the spirit in which the ' leaders ' of the American profession, for
w e will still venture to call them so, have met the recent crisis is one
which reflects the highest possible credit upon them. We hardly know
which to praise most, their patient suspension of action until the Chi-
cago meeting had confirmed the spirit of the proceedings of the meet-
ing at New Orleans, or their swift and unanimous protest and with-
drawal from the Congress when definite action was at length called for.
The only hope for the Congress — the only possibility of maintaining
the dignity of the profession — lay in such firm and united action on
their part, and the effect of this action has been so favorable that there
already appears to be a much more hopeful feeling in the States as to
the prospects of a peace with honor. The organizers of the revolt are
meanwhile making frantic efforts to prevent further resignations, and
are even said to contemplate throwing over Dr. Shoemaker, on the score
of his supposed unpopularity. But we may take it that no concessions
on their part will be accepted short of unconditional surrender and full
recognition of the authority and acts of the original committee. These
are the essential preliminaries to the holding of any International Con-
gress at all, and every day increases the prospect of their general ac-
ceptance. The sooner they are accepted the better. There will then
be still two years in which to bury the hatchet, two years in which to
prepare a Congress which shall ' whip creation.' We had all made up
our minds for that, and shall be disappointed with anything less."
The " Pacific Medical and Surgical Journal and Western Lancet "
says :
" The recent action of the American Medical Association has re-
duced all the arrangements for the approaching Congress to a state of
chaos. In an unguarded moment it accepted the doctrine that none
but members of the association, or of societies in affiliation with it,
■were eligible for seats in the Congress, and consequently refused to
indorse the appointments made by Dr. Billings's Committee of Ar-
rangements, who had taken the broad view that delegates should be
selected from all regular practitioners. The so-called new code was
made to play an important part in the discussion, and, consequently,
such men as Emmett, St. John Roosa, Shrady, and Knapp were declared
unqualified to become members of the Congress. In consequence of
the above-quoted restrictions, the medical profession in Boston, Balti-
more, and Philadelphia have refused to take any part in the proceed-
ings, so that the American delegates will not be representative of the
profession. Without doubt, the American Medical Association is the
representative of the profession, and therefore the Congress convenes
under its auspices ; but it should be borne in mind that this latter body
is an assembly of medical men, and not a convention of societies, and
is not therefore bound by any code of ethics. The profession in every
country has its own rules for the guidance and government of its mem-
bers, and therefore the code of the American Association can not be
taken as the criterion for the fitness of any man to occupy a seat in
the Congress. When this question was first discussed we denied the
prudence of the refusal to indorse the work of the first committee,
although we admitted the power to do so ; but a further consideration
of the above facts, together with the recollection that the invitation
was extended in the name of the profession in America, leads us to
believe that every regular practitioner of medicine is eligible for a seat
in the Congress. It is utterly absurd to debar men who have in for-
mer years occupied an honored place in that body, or those — such as
Fordyce Barker, Emmett, Shrady, Loomis, and Jacobi— .whose names
are on the lips of every intelligent practitioner in Europe, merely be-
cause they hold somewhat broad views on a question of medical poli-
tics. If any one has exceeded its power, it is the American Medical
Association, which was intrusted by the profession at large with the
honor of making suitable arrangements, but not with the power of
making laws which will exclude many of those from whom it will only
be too ready to receive subscriptions.
"While the American Medical Association is thus caviling and
squabbing, it seems to forget that its intended guests are being thor-
oughly informed of all those curtain lectures, and are not at all likely
to leave their practice and cross the Atlantic for the purpose of parti-
cipating in a party strife. The medical men of Europe promised to
meet with those of this country for the purpose of engaging in scien-
tific discussion, and will be amazed to learn that the noblest of Ameri-
ca's children, who have followed in the footsteps of ^Esculapius, are
no longer considered members of the regular profession by their coun-
trymen.
" Unless some satisfactory arrangement is arrived at within the next
few months, the money necessary for the successful administration of
the Congress will not be forthcoming, as the dissatisfaction with the
action of the American Medical Association is very widely spread. We
are told by the journal of the association that this is unwarrantable,
for the changes made by the new committee were not of any great im-
portance. We differ from our cotemporary in this opinion, but its
truth would make the action of the association even more unpardona-
ble, since only the most serious errors on the part of the old committee
could justify the course which has bean adopted.
"The proceedings of the revised committee which met at Chicago
have especial interest for the profession of this State, as a serious
change has been made in the personnel of those who were to have rep-
resented them at the International Congress.
" Dr. Levi C. Lane, whose aid in perfecting the arrangements was re-
quested by the original committee of seven, has not only been dropped
from the list of vice-presidents and from his position on the surgical
section, but, as the matter now stands, is debarred from even enter-
ing the Congress as a delegate, for we learn that he was dropped on the
pretext of his being a new-code man. When the New York State Medi-
cal Society adopted the new code, as it is called, and by so doing vio-
lated the tenets of the code of the American Medical Association, that
association very properly denied to their delegates seats in its conven-
tion, and we at first thought that there was reason for dissatisfaction
when these same men were appointed to take part in the International
Congress. Further deliberation has made the difference between the
two cases clear, and we believe, since the invitation was given and
accepted in the name of the profession, that no regular practitioner
should be excluded from a purely scientific meeting because his code
differs from that of the American Medical Association.
" The committee had the power to make what appointments they
chose, and in most instances closely followed their instructions, viz., to
have regard for geographical representation, and not to appoint any
new-code men. If, however, Dr. Lane, who had been in active corre-
spondence with the Committee of Arrangements, and had been giving
for the past year much valuable time and hard labor to the advance-
ment of the arrangements for a successful Congress, was not reap-
pointed because he was of the new code, a sad mistake has been made
and a gross injustice has been done.
" As far as medical politics are concerned, there are no new-code
men on this coast, nor in fact anywhere in the United States except
New York alone.
"At the annual meeting of the California State Medical Society in
1882, the year in which Dr. Lane was elected president, resolutions
were introduced to test the feeling of the members. Had these been
carried, the action of the New York State Society would have been in-
dorsed, and members have been allowed to consult with all legally quali-
fied practitioners of medicine. They were, however, laid upon the
table. Since that time no action has been taken, and, consequently,
' new CO distil ' does not exist in this State. Dr. Lane is in good stand-
ing in the State Society, and the State Society with the American Medi-
cal Association, and therefore to say that he was a ' new-code ' man can
only have been used as an excuse to prevent his reappointment.
" A removal such as this, for such a reason, will produce an ill-feel-
ing among the profession of California, which will only help in prevent.
252
MISCELLANY.
|N. Y. Mkd. Jon;.
ing the meeting of the Congress upon American soil being an honor to
America."
Warm Baths at the White Sulphur Springs. — The managers of
this popular health-resort call attention to a new method adopted by
them for heating the water of the spring, which, they think, promises
to be productive of the same good effects that are experienced from
bathing in thermal waters. The heating is effected by steam in the
vessel in which the water is to be used ; consequently the heat is never
so great as to cause much precipitation of the saline constituents. An
additional advantage is, that more hot steam may be let in from time
to time, so as to keep up the temperature of the bath.
THERAPEUTICAL NOTES.
Ergot as a Remedy for Hiccough. — Dr. E. Bonavia, of the British
Indian Medical Department, in a short communication to the " Lancet,"
after mentioning the usefulness of ergot in various haemorrhages; says :
" Very few, however, may have heard that ergot will cure hiccough.
Last autumn there was in this district an extensive epidemic of inter-
mittent fever. The police hospital was full of fever cases. One day a
policeman was admitted with an obstinate hiccough. He said he had
had it for some days, and had no other ailment. I tried many reme-
dies— sedatives, narcotics, antispasmodics, and counter-irritants. I ex-
amined his body to see whether there might not be some latent hernia
in any part which might be the cause of it, but found nothing. I gave
him a large antispasmodic enema, and then a strong purgative. The
hiccough went on. 1 next tried chloroform and subcutaneous injec-
tions. As long as their effects lasted, freedom from the distressing
spasm was experienced. Then it came on again with unabated force.
The patient began rejecting his food and everything he took by the
mouth. The case was taking a serious aspect, and I thought death
would ensue. As a last resource, I ordered the liquid extract of ergot
in drachm doses. I did this simply because I knew it had a decided
action on muscular fiber. The first dose moderated the spasm, the
second did further good, and the third or fourth stopped it altogether.
The patient had some rest, but later on the hiccough returned. Three
or four doses stopped it again ; it never returned, and the man was
well. Recently another case was admitted with a similar obstinate hic-
cough. My hospital assistant gave the liquid extract of ergot at once ;
after some doses the hiccough was stopped and did not return. I have
often given this extract in drachm doses frequently repeated, and have
never observed any disadvantages from it. As to the cause of this
idiopathic hiccough, I think it was a chill."
The Treatment of Simple Acute Diarrhoea. — Dr. J. K. Spender,
of the Mineral Water Hospital, Bath ("Brit. Med. Jour."), thinks that
the management of that common malady, alvine catarrh, has never been
raised to the scientific level of many diseases of rarer occurrence, so
that there is always a little uncertainty in the prognosis. He refers to
a formula published by Dr. David Young, of Florence, in the " Prac-
titioner " for March, 1875; about two minims of castor-oil were com-
bined with three or four minims of the British Pharmacopoeia solution
of hydrochlorate of morphine, and rubbed into an emulsion with gum
arabic. To this were added spirit of chloroform and a little syrup.
This dose was to be repeated every hour or every two hours, according
to the urgency of the case. If the diarrhoea was chronic, the quantity
of castor-oil was increased ; if there was much pain, more morphine
was prescribed. He has found Young's mixture extremely valuable in
nearly all forms of sudden and acute diarrhoea, such as are often seen
during August and September, and scarcely less useful in some chronic
conditions of irritable bowel which have baffled the so-called routine
remedies ; but he thinks that, when the castor-oil and morphine fail, or
do little good after four or five doses, it may even aggravate the malady
to continue their use. Warm milk with lime-water is the best food, a
mustard poultice may be put over the stomach, and there should be ab-
solute rest in bed.
Strophanthin, a New Diuretic. — At the recent meeting of the
British Medical Association, Prof. Fraser (Ibid.) read a paper on the
apocynaceous plant Strophanthus hispidus (S. kombe, Oliver), from
which an arrow-poison is prepared in many parts of Africa, called
kombe in the Mangauga district, and inie in Senegambia and Guinea.
The plant is a woody climber, and flowers in October and November.
The follicles vary in length from ten to twelve inches, and contain from
one hundred and fifty to two hundred seeds, each weighing about half
a grain, and bearing a beautiful plumose tuft, placed at the extremity
of a delicate stalk. They contain no alkaloid, but are rich in an active
principle which the author calls strophanthin, a crystalline substance of
intense activity, which seems destined to play an active part in our list
of heart remedies. In physiological action it is allied to digitaUp and
other members of the digitalis group. It has been used, both experi-
mentally on animals and clinically in the wards of the Infirmary at
Edinburgh. The dose for hypodermic use is from one one-hundred-
and-twentieth to one sixtieth of a grain.
The Treatment of Weakness of the Heart's Action. — In the course
of a recent lecture on " Arterial Atheroma and Cardiac Affections," M.
Lancereaux (" Union med.") remarked that the treatment of systolic
weakness should vary with the nature of the case. When it depends
on dilatation of the right heart, recourse should be had especially to
purgatives, for digitalis is no longer efficient, and this is readily under-'
stood at the autopsy, when the right heart is found with its walls hard-
ened and stiffened, and remains gaping after it has been cut open.
When, however, the weakness is due to atheroma of the coronary arte-
ries, even if at the same time the heart is a little steatosed and scle-
rosed, digitalis acts more energetically, and it is of great service to use
it in conjunction with other diuretics. The author often uses the fol-
lowing formula :
Scammony,
Squill,
Digitalis,
each 15 grains.
•nan> [-each 75 grains.
italis, ;
Divide into twenty pills, from four to six of which are to be taken
daily, a milk diet being prescribed at the same time.
A Mixture for Whooping-cough. — According to a contributor to
the same journal, M. H. Roger prescribes the following formula:
Tincture of belladonna 5 drachms;
Tincture of valerian,
Tincture of digitalis
For a child two years old, begin with five drops daily ; increase the
amount by five drops each day until it reaches thirty drops. The initial
dose and the increment are ten and fifteen drops respectively for chil-
dren between two and five years old and for patients who are still older.
If the valerian is not well borne, tincture of musk may be used in-
stead. Where nervous and spasmodic symptoms predominate, the au-
thor resorts to chloroform, giving to children between two and five
years old from six to thirty drops daily, in two ounces of gum julep.
The Administration of Terpene. — M. Germain See ("Rev. mid.
franc, et Strang.") gives the following formula:
Terpene 150 grains;
Alcohol, 85 per cent 5 ounces ;
Water 1 J ounce.
Two teaspoonfuls to be taken daily, in divided doses, with the meals.
The author states that when the drug is administered in this way or,
better still, in the form of pills, it does not produce the slightest de-
rangement of the digestion.
Hydrochloric Acid in the Treatment of Dyspepsia. — In an article
on the treatment of diseases of the stomach (" Ztschr. f. klin Med." ;
" Dtsch. Med.-Ztg."), Prof. Talma, of Utrecht, lays stress on fermenta-
tion of the contents of the stomach as being either the cause of dys-
pepsia in the great majority of instances or at least the leading factor
in keeping it up. This fermentation is generally due to a deficiency of
hydrochloric acid, an artificial increase of which is therefore indicated.
For adults, the author recommends a mixture of fifteen grains of the
acid and twenty-two ounces of water to be taken in the course of
twenty-four hours. The doses had better be taken after eating, and
sensitive patients may take them lukewarm. He has observed excel-
lent results of this treatment after the failure of long-continued alka-
line medication, and even in cases of ulcer or cancer of the stomach he
has seen it subdue such of the symptoms as were due to abnormal fer.
mentation.
THE NEW YORK MEDICAL JOURNAL, September 5, 1885.
ectures antr ^bb i-* ss.es.
LECTURES ON
ELECTRICITY IN MEDICINE,
DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI-
VERSITY OF VERMONT, BURLINGTON,
By AMBROSE L. RANNEY, M. D., New Yoek.
{Continued from page lJfi.)
SPECIAL ELECTRO-THERAPEUTICS.
We have thus far discussed the various methods of em-
ploying electricity in a general way, and there remains for
us to consider how we shall proceed in employing this
agent when special organs are diseased. I would preface
my remarks upon this field with the statement that the
curative properties of electricity must, of necessity, be modi-
fied by the pathological conditions which exist in each indi-
vidual case. The prognosis is naturally more grave in some
conditions than in others.
For example, a patient who has motor paralysis which
is due to degenerative changes in the cells of the anterior
horns of the spinal gray matter will not usually recover the
power of motion completely, while he may do so if the pa-
ralysis be due to a cerebral or spinal lesion which is not
accompanied by degenerative nerve-changes. Again, all
forms of functional nervous derangements are more amena-
ble to electrical treatment (if judiciously employed) than are
the graver results of organic disease of the nerve-centers.
A muscle which has atrophied from disuse can usually be
restored, while one which has wasted from imperfect nutri-
tion (resulting from a degenerated nerve) may withstand all
efforts to improve it. The therapeutical use of electricity
is subject to the same influences as that of any other reme-
dial agent, and the prognostic conditions are not always the
same even among cases of the same nature.
In previous lectures I have given you many hints relat-
ing to the differential diagnosis which you will be called
upon to make in nervous diseases, and enough has been said
in reference to the anatomy and physiology of the nervous
system to assist you in properly interpreting abnormal ner-
vous phenomena. I shall therefore give you, in closing,
directions only as to how to employ electric currents upon
different parts of the body, without entering to any extent
into the causation of the symptoms which you will be called
upon to treat. Remember, however, that accuracy of diag-
nosis is the basis of cure in a large proportion of the cases
which you will meet.
ELECTRICITY IN CEREBRAL AFFECTIONS.
Experiment has shown beyond dispute that galvanic
currents can be made to pass through the substance of the
brain when inclosed within the skull. It is much less cer
tain whether the same may be said of faradaic or static
currents. The beneficial results which are obtained by the
two latter (and possibly many of the effects of galvanism
as well) upon cerebral diseases are to be attributed, in my
opinion, chiefly to the alterations produced in the blood
supplv of the brain. Some of the most remarkable results
obtained by neurologists from the employment of electricity
upon the head itself or the cervical ganglia of the sympa-
thetic are unquestionably due to an alteration produced in
the caliber of the cerebral vessels. I have never been con-
vinced that organic lesions of the brain can be cured by the
direct use of this agent on that organ. On the other hand,
I am fully satisfied that the symptoms of cerebral hyperae-
mia and anaemia are directly influenced by galvanism and
static electricity. I believe that any unprejudiced mind
can be readily convinced of the scientific accuracy of this
conclusion. I have treated many patients (who gave undis-
putable evidences of basilar hypersemia by the deflections
of the needle of a calorimeter), and have brought them to
a state of perfect health within a space of a few weeks by
galvanism of the head. The calorimeter confirmed the cure
in these cases by the absence of deflection which existed
before treatment was commenced. In some instances of
this condition static electricity proves a very valuable ad-
junct to galvanism. I will give you in detail a few of the
methods which, in my experience, may be employed in
cerebral diseases with a prospect of great benefit to your
patient.
Cerebral Hyperemia. — First ascertain by means of a
calorimeter the situation and extent of the congestion.
Test all parts of the head. When necessary, do so by sepa-
rating the hair and bringing the poles as closely as pos-
sible in contact with the scalp. It is not necessary, as a
rule, to shave the head. In case very accurate observations
are demanded, this step may have to be taken — as, for ex-
ample, when a cerebral tumor is suspected to exist.
At the nape of the neck, over the mastoid processes,
upon the temples, and over the forehead, no hair exists to
interfere with the determination of the relative temperature
of the two sides, or of different regions of the correspond-
ing side. The calorimeter will aid you in diagnosis and
treatment ; if properly used, it is invaluable.
The following are the steps in treatment most generally
useful :
(1) Apply the cathode to the nape of the neck, close to
the skull, and the anode over the forehead. Make stabile
applications for one or two minutes to each side of the fore-
head, the cathode remaining stabile. (2) Make labile ano-
dal applications to the forehead transversely for one minute.
(3) Move the cathode to the mastoid region of each side,
place the anode centrally on the forehead, and continue
each stabile application for from thirty seconds to one
minute. This may make the patient dizzy. (4) Do not
use a current which produces pain to the patient, but have
as great intensity as he can comfortably bear. (5) Never
reverse the current when the poles are on the head.
These applications may daily be alternated with " insula-
tion " and the " electric head bath" if you possess a static
machine. The sittings should occur daily until the symp-
toms are cured, and the calorimeter ceases to show its pre-
vious deflection.
It is sometimes well to stimulate the superior cervical
ganglion by placing a small anode in the fossa behind the
254
RANNEY: LECTURES ON ELECTRICITY IN MEDICINE.
[N. Y. Med. Joob.,
angle of the jaw, and the cathode on the seventh cervical
spine, and to slowly interrupt the current. Caution must
be exercised against employing too strong currents.
Flo. 40. — A Schematic Representation of the Distribution of an Elec-
tric Current applied unilaterally through TnE Head (after Erb).
The anode ( + ) rests above the ear of the left side. The cathode (— ) is sup-
posed to be at the nape of the neck, and to exert its influence as far as the
line drawn horizontally across the neck.
Finally, active faradization of the limbs is sometimes
necessary, in order to draw the blood to the limbs. It is
not well to employ this step if it causes an elevation of tem-
perature.
The effects of this treatment should be to relieve the
pain or sense of fullness in the head, the vertigo on rising,
the mental confusion or distress, the insomnia, and the
many other symptoms peculiar to this condition ; and to
steadily reduce the calorimeter deflections when the poles
are in contact with homologous parts.
Cerebral Anaemia. — I should advise you to begin the
use of very weak galvanic currents after an attack of embo-
lism. I believe that currents of this kind sent transversely
through the head from the temples, and occasionally in the
antero-median plane, assist in absorbing the collateral oede-
ma and cause a diminution of the collateral hyperaemia. I
prefer to use the cathode on the side of the embolic obstruc-
tion when transverse currents are employed. In my opin-
ion, it tends to promote absorption and to contract the ves-
sels far more than the anode. The paralyzed muscles should
be treated separately, by methods given in detail later.
Some four years ago Lowenfeld published some deduc-
tions relative to the action of galvanic currents upon the
brain, based upon experimental researches. Although their
accuracy has been justly called in question by authors of
note, my own experience leads me to confirm them in part
and to attach some importance to them. These conclusions
were as follows: (1) Anode at forehead and cathode at
neck causes contractions of the vessels of the pia ; (2) anode
at neck and cathode at forehead causes dilatation of the
vessels of the pia; (3) when transverse currents are em-
ployed, the cathode causes contraction of adjacent vessels,
and the anode dilatation.
When cerebral anaemia of a general character exists (as
a manifestation of poverty of the blood, defective heart-
power, etc.), general faradization, central galvanization, and
static electricity by insulation are often of material benefit.
The removal of the cause by judicious medication, etc., is,
of course, vital to successful electrical treatment.
Hemiplegia of Cerebral Origin. — A very large pro-
portion of patients with hemiplegia from cerebral causes owe
the paralysis of their limbs to haemorrhage, softening, or
Fig. 41. — A Schematic Representation of the Course of Electric
Currents sent Transversely through the Head (after Erb). Tbe
cathode (— ) is represented as placed on the side of the lesion.
embolism. The electrical treatment should be directed to
both the brain and the muscles. It should not be com-
menced (save in the case of embolism) until a month has
elapsed since the attack. Each patient's susceptibility to
the agent should be carefully studied ; and the strength of
current employed should be modified accordingly. The
muscles may be treated by faradization or galvanization, or
by the static current (indirect sparks being drawn from the
paralyzed limbs). The brain should be subjected to gal-
vanization only, or to static insulation.
If the patient fails to show improvement within a month
after the treatment has been daily applied, or if the im-
provement of the first few days is rapidly lost in spite of
continued treatment, the prognosis, as regards marked ame-
lioration of the paralysis by electrical applications, is grave.
Hemiancesthesia is best treated by the wire-brush upon
the dry skin in connection with the secondary faradaic cur-
rent. I have also obtained some remarkable effects with
the combined current (as before stated), and also with the
static current, in cases where the faradaic current was in-
effective.
Post-paralytic rigidity (occurring late) is the result, in
most cases, of secondary changes within the spinal cord.
The supervention also of pigmentation of the nails, cedema,
a shiny skin, disease of the joints, and other evidences of
trophic alterations, points to a serious and often perma-
nent destruction of the nerve-centers.
Hints which have been given under the head of general
electro-therapeutics will guide you in modifying the treat-
ment according to the exigencies of each individual case.
The remarkable improvement which some hemiplegics ob-
tain through the instrumentality of electrical treatment
should impress you with the necessity of employing it long
enough to ascertain whether its continued use is indicated.
Monoplegia or Monospasm. — These conditions are
particularly indicative of cortical disease. The muscles
affected are a guide to the convolution attacked. I have
covered this field in previous lectures.* The indication in
such a case is to improve, if possible, the nutrition of the
diseased part directly by galvanism, and also to stimulate
the muscles functionally associated with it. I employ for
this purpose a " medium " electrode over the diseased con-
* See " Med. Record," May and June, 1834.
Sept. 5, 1885.]
volution, the indifferent electrode being placed over the
center of the sternum. It is my custom to employ both
poles to the head for an interval of two minutes each at a
sitting. The monoplegic limb may be treated by labile gal-
vanic applications, the wire-brush and faradization, or the in-
direct spark by means of a static machine.
Duciienne's Disease. — The morbid changes in the nu-
clei of the medulla which accompany bulbar paralysis may,
in some cases, be held in check for a while and the symp-
. toms markedly improved by placing the positive electrode
(of large size) at the nape of the neck and as close as pos-
sible to the foramen magnum, and applying the negative
electrode (covered with absorbent cotton and attached to a
long handle) successively to the pharynx, fauces, tongue,
cheeks, and lips. As strong a current as the patient can
easily endure should be used. The duration of the sitting
should not exceed five minutes. It is well to complete the
sitting by passing transverse currents through the neck, so
as to excite the muscles concerned in deglutition. Some
authors recommend the employment of currents through
the head, both longitudinally and transversely.
electricity in spinal affections.
There are various ways of bringing the spinal cord un-
der the influence of electrical currents. The method of
application selected in any individual case will depend
somewhat upon the symptoms which the patient presents,
and also upon the character and seat of the lesion. The
diagrammatic cuts of Erb, which illustrate the diffusion of
electrical currents, show in a graphic way the effects of
close approximation and wide separation of the poles. We
may also modify some of the morbid conditions of the
spinal cord by electrization of the extremities when the in-
different pole is placed over the spinous processes. It is
well to increase the size of the electrodes proportionately to
the strength of the current employed.
Fig. 42.— A Schematic Representation or the Distribution and Den-
sity of the Threads op Current with regard to their entrance
into the Spinal Cord (after Erb). In a the poles are placed near
each other. In b the poles are more widely separated. The size of the
electrodes shown in the cut is the same for both the anode and cathode.
Fig. 42 illustrates the effect of separation of the poles
when applications of electricity are made to the spinal col-
umn. Some of the threads of current depicted are ren-
255
dered ineffective on account of their diffusion. This is
made more apparent in Fig. 43.
Fig. 43. — A Schematic Representation of the Density of the Cur-
rent UPON APPLICATION OF THE ELECTRODES TO THE SAME SURFACE
AND in Close Relation to Each Other (after Erb). The dotted lines
indicate the ineffective threads of current. The shaded portion represents
the zone of greatest intensity.
ELECTRIZATION OF THE SPINAL CORD.
To treat properly of the various methods which may be
used when the application of electrical currents as a thera-
peutical measure for the relief of spinal diseases seems in-
dicated, it would be necessary for me to enter into greater
detail regarding spinal diseases than the time allotted to
these lectures will permit of. I am reluctantly forced,
therefore, to summarize somewhat hastily the main points
which my experience with this agent leads me to indorse.
Most of you are probably already familiar with the patho-
logical changes which exist in connection with the more
common diseases of the cord ; but, if any of you are not so,
they should first be 'studied and thoroughly mastered before
you can hope to successfully combat them.
Galvanic currents are of greater service in the treatment
of spinal diseases than faradaic or static — chiefly on account
of the depth of the tissues affected and the chemical and
molecular changes which galvanic currents tend to induce.
Spinal electrodes should be of large size.
The applications may be either stabile or labile, the
former being of the greatest benefit when the spinal lesion
is circumscribed in extent, and the latter when a larger part
of the spinal cord is affected. If labile applications are
indicated, the movements of the electrodes should be made
somewhat slowly.
In directing galvanic currents to the cervical and upper
dorsal segments of the cord, it is well to place one electrode
of medium size behind and below the ear alternately on the
two sides of the neck, while the other is applied to the
spine.
Points of tenderness to pressure alone/ the spine should
be subjected to stabile applications of the anode. They
should be sought for in each individual case with care and
separately galvanized.
The strength of the currents employed should be modi-
fied in individuals by the condition which is presented for
treatment. Weak currents of from two to five milliamperes
HAN NET: LECTURES ON ELECTRICITY IN MEDICINE.
256
EANNEY: LECTURES ON ELECTRICITY IN MEDICINE.
[N. Y. Med. Jodr.,
act best, as a rule, when excessive irritability of the organ
exists ; chronic pathological conditions respond better to
currents of greater intensity. I often use eight to twelve
milliamperes of current in chronic cases.
It is advantageous, in some subjects, to make electrical
applications to the limbs when the cord is affected. Stimu-
lation of the peripheral nerves and the muscles connected
with the segments of the cord involved should be particu-
larly aimed at, although the electrization of the skeletal
muscles and the skin should not be exclusively confined to
the limits thus indicated. It is my custom to employ the
"combined current'''' (previously described) when applica-
tions to the limbs are thus made. This form of current is
particularly indicated when the muscles exhibit a tendency
toward atrophy. The electrode which rests upon cervical
or lumbar enlargements of the spine should be of large
size, while that used upon the limbs should be of medium
size, so as to direct the combined currents to the nerves or
muscles affected.
If galvanism alone is used upon the limbs in spinal dis-
ease, it is often beneficial to the patient to break the current
by an interrupting electrode, or to reverse its direction by
means of the commutator.
Some authorities advocate faradization of the vertebral
region and of the limbs in conjunction with galvanic applica-
tions. I have seen in a few instances some remarkable
effects follow the employment of the wire-brush alone in
polio-myelitis of children, and I can see no reason to doubt
its occasional efficacy in other forms of spinal disease.
In some unexplained way the excitation of muscular
action and stimulation of the cutaneous nerves exert in
many instances a remedial effect upon lesions of the spinal
cord.
It is not always possible (as, for example, in polio-mye-
litis) to excite muscular action by faradism alone. In these
cases interrupted galvanic currents, or the " combined cur-
rent" (galvano-faradaic), will accomplish the desired end.
I have repeatedly observed beneficial effects of this treat-
ment in locomotor ataxia, and Rumpf has published some
cases which sustain this view in which the wire-brush was
used upon the arms and legs daily for about five minutes.
In all acute inflammatory disorders of the cord I depre-
cate the use of electrical applications. When the acute
stage has passed, or when the disease has assumed a chronic
type, many of the effects of the disease (as, for example,
muscular paralysis, rectal or vesical complications, incipient
caries, anaesthesia, etc.) may often be greatly relieved by its
judicious use. The current-strength employed in such cases
usually varies from five to eight milliamperes. The appli-
cations should be made daily. When possible, it is impor-
tant that you localize early the seat of the structural lesion
and concentrate the treatment, for a while at least, upon
the segments of the cord involved. The muscles, skin,
bladder, rectum, etc., should be separately subjected to the
influence of electricity in case they exhibit a loss of func-
tion.
ELECTRICITY IN PARALYSIS OR PARESIS.
Hypokinesis may be due to many different conditions,
hence its electrical treatment and prognosis must vary in
accordance with the cause which excites it. You should
remember that paralysis of a muscle is only symptomatic of
other conditions, such as lead-poisoning, diphtheria, hyste-
ria, mechanical pressure upon a motor nerve, severance of a
motor nerve, destructive processes or inflammation within
the motor cells of the brain or spinal cord, and changes in
the vessels. All of these tend to impair either the generat-
ing power of a motor center, or the conducting power of a
motor fiber.
Respecting the application of electricity to the seat of
central lesions (i. e., lesions of the brain or spinal cord) in
cases of motor paralysis, De Watteville pertinently remarks
as follows :
" It is true that we have too often but a very imperfect
idea of those processes in the nerve-centers upon which the
symptom depends, and that we have no right to assume
that the current has any specific curative influence upon
any one of them ; still, as a justification for central treat-
ment in such cases, we may plead our very ignorance, we
may urge the poverty of our therapeutical arsenal in arms
wherewith to combat our enemy, and may also invoke the
possibility of at least staying its progress by promoting nu-
trition of the surrounding portions of the nervous structures
threatened by its invasion."
When the lesion directly affects the conductivity of a
nerve, we have reason to believe that the direct influence
of electrical currents upon the lesion tends to overcome
the resistance offered to conduction by the disease-process,
and facilitates the subsequent transmission of voluntary
stimuli.
There are certain general rules that are applicable to the
electrical treatment of paralysis of motility. These may
be stated as follows :
1. The treatment should not be alone confined to the
region of the paralyzed muscles.
2. The seat of the exciting lesion should be ascertained
early, if possible, and subjected to the influence of this
therapeutical agent in an intelligent way.
3. If the motor paralysis is accompanied by anaesthesia,
hyperaesthesia, or other sensory disturbances, or if the vaso-
motor system of nerves be apparently implicated, the wire-
brush may often be used with advantage upon the skin in
the vicinity of the lesion, and also over the muscles para-
lyzed.
4. Faradaic currents (provided they excite muscular
action), or the cathode-pole of a galvanic battery (with in-
terruptions of the current), are of use in exciting the con-
ductivity of the nerve-tracts affected. Static electricity is
also of great utility in inducing muscular contractions, and
is less painful than faradism or galvanism.
5. The " combined current " (galvano-faradaic) is chiefly
of service in overcoming trophic disturbances, which often
manifest themselves in connection with motor paralysis.
6. I prefer labile applications to stabile in applying
either faradism or galvanism to the muscles. Stabile appli-
cations are preferable to labile when the brain, spinal cord,
or peripheral nerve-trunks are to be influenced.
7. Never begin the use of electricity immediately after
the onset of paralysis (when due to a central lesion). It
Sept. 5, 1885.J
ELLIOT: PYROGALLIC ACID AND COLLODION.
257
is always best to wait until all danger of exciting a recur-
rence of the attack by stimulation of the nerve-centers has
passed.
(To be continued.)
(frigtnal Communications.
PYEOGALLIC ACID AND COLLODION: A
TREATMENT FOR PSORIASIS.
By GEORGE T. ELLIOT, M. D.,
ASSISTANT VISITING PHYSICIAN, NEW YORK SKIN AND CANCER HOSPITAL ; AT-
TENDING PHYSICIAN, DEMILT DISPENSARY, ETC.
For many years innumerable attempts have been made
by dermatologists to obtain some form of application for
the treatment of diseases of the skin which would be an
advance on, and which could also supersede, the usual time-
honored methods, such as ointments, etc., accompanied as
thev are by certain objectionable features which cause their
use to be, as a rule, a source of considerable annoyance.
The soiling of the linen, the discoloration of the skin, etc.,
attending the application of some of the most useful medi-
caments, have always been serious evils. To remedy these,
or at least as much as possible to remove them, we have
had in the past few years many preparations brought for-
ward in which the drug to be used has been incorporated
in gelatin, traumaticin, etc., or has taken the form of plas-
ters, as recommended by TJnna, and known as "Unna's
Pflastermull." Each of these has had its supporters, and
has enjoyed reputation and extensive use for a longer or
shorter period of time, finally to be relegated to a greater
or lesser disuse, leaving dermatologists still seeking for that
application which would be generally acceptable as regards
cleanliness, and in which the proper action of the drug
used would not be interfered with or diminished. Many
skin diseases, owing to their chronicity and the length of
time necessary to cure them, especially call for some such
application, for the continued use of a treatment offensive
alike to the sight and smell can only disgust the patient,
until he finally prefers his disease to the remedies used
therefor. Among these diseases, psoriasis is prominent.
For its cure a little of everything, both externally and in-
ternally, has been recommended, from the old-time tar —
which, however, always gave most satisfactory results — to
the more recent chrysarobin and pyrogallic acid.
It was in regard to the treatment of this disease that,
dissatisfied with the methods in practice — objectionable
features being to a certain extent present in all of them — I
sought to remedy them, not by any new medicament, but
by a new combination of remedies already in use. Though
speaking of the treatment of psoriasis, I do not, however,
intend to review the many methods which have been recom-
mended, these being dealt with in extenso in works on gen-
eral dermatology, and I desire to limit myself only to the
method which I have been using entirely for now nearly
a year, being one which has given me most satisfactory
results. Still, I would briefly mention one method, since
the formula which I use differs from it only in regard to its
principal and active ingredients.
A solution of chrysarobin in collodion was first used and
recommended in Europe by Sesemann, and here by G. H.
Fox, who improved its action by the addition of salicylic
acid. It has enjoyed, since first brought out, deserved-
ly great repute, has been extensively used, and is a valuable
addition to our list of remedies. Unfortunately, however,
the chrysarobin now obtainable in the market is so unre-
liable and impure that the service which it formerly rend-
ered has become very uncertain and much diminished, so
that the results, even from strong solutions, are far from satis-
factory. I have found another objection to chrysarobin, and
that is, that only a portion of it is soluble in the collodion,
and, when used in a tcn-per-cent. or twenty-per-cent. solu-
tion, there is always a considerable sediment, which causes
it, when shaken up, to be of a more or less gruelly consist-
ence. This, naturally, is an objectionable feature, depriving
the application, to a certain extent, of cleanliness in its ap-
pearance, and giving the skin painted with it an unsightly
look.
These objections I sought to remedy, and, having always
had a predilection for pyrogallic acid, I determined to sub-
stitute it for the chrysarobin. This acid was first intro-
duced into dermatology by Jarisch, and was recommended
by him for the treatment of psoriasis, but it has since then
been used in many other diseases of the skin. It was re-
ceived with great favor at first, and the benefits derived
from it were extolled, until a few unfortunate deaths occur-
ring from its application, as reported by Neisser, Besnier,
and others, caused dermatologists to become chary in its use
and to prefer the safer chrysarobin. If used properly, how-
ever, there is no more danger from the one than there
is from the other. The deaths reported were indubitably
due to the careless manner in which the acid was em-
ployed, a ten-per-cent. ointment having been rubbed in over
the entire body every day, a procedure which might in all
probability give some* unfavorable results, even if some less
absorbable or more innocuous drug had been used. In
Jarisch's hands, and in the practice of Kaposi and others, I
have always seen it give the greatest satisfaction, and I
have not as yet seen any untoward result occur. On the
coutrary, in the cases which I saw treated by them, and in
my own cases, I have only been able to observe a quicker
and more complete disappearance of the eruption when
pyrogallic acid was used.
So far as I have been able to ascertain, it was received
with little favor in America as a remedy for psoriasis,
possibly owing to the already mentioned deaths occurring
from its use, and also to its always having been made up
as an ointment, a method of application which, to say the
least, is very disagreeable on account of the black color
which it acquires after exposure to the light, and the de-
struction of the patient's linen. The dark pigmentation
remaining after its use and the ease with which a derma-
titis arose were also potent objections to it.
In order to avoid and remedy, if possible, these objec-
tions, I determined to try an application of pyrogallic acid
dissolved in collodion, substituting it for chrysarobin. The
258
BILLINGS: CHOLEROID
ALVINE DISCHARGES.
[N. Y. Med. Jorn.,
immediate and patent advantages shown have caused me
to use this solution in all cases of psoriasis to the exclusion
of every other method of treatment. The strength of the
solution has varied from 10 to 15 per cent., and I have not
yet found it necessary to increase this strength. The for-
mula reads as follows :
IJ. Acidi pyrogallici 3 jss.- 3 ij ;
Acidi salicylici 3 ss. ;
Collodii flex ? ij.
M. et ft. sol.
The first advantage which I noticed was the complete
solubility of the pyrogallic acid, the solution being per-
fectly clear and without any sediment whatever. It was at
first limpid and clear, but, after exposure to the light, it
gradually became brown in color, and I found it was better
to keep it in a dark-colored bottle. After applying it to
the skin it becomes darker, and may even appear black.
The salicylic acid, which had been added to the chry-
sarobin collodion by Dr. G. H. Fox, I retained in the pyro-
gallic collodion, owing to the peculiar action which it
exerts on the horny epidermis, though it has itself no direct
curative effect over the disease. Unna, of Hamburg, drew
attention in 1883 to the fact that certain of the medica-
ments called antiseptics, when used in the strength neces-
sary for antisepsis, had a peculiar effect upon cornification,
preventing keratoplasia through their possessing a kerato-
lytic power. Whether this power acts by dissolving out the
keratohyalin necessary for cornification, or whether it pre-
vents its formation, is still sub judice. However, when my
attention was directed to the fact by his article on " Derma-
toplasie und Keratoplasie " (" Berlin, klin. Wchschr.," No.
35, 1883), it offered me an explanation of a condition which
I had often observed when using salicylic acid in the treat-
ment of various forms of skin diseases. A surface to which
it was applied could be brought to a certain point in heal-
ing, and then a retardation in cornification would ensue.
Epidermis would form, but it remained soft and easily re-
movable, and this condition would persist as long as the
salicylic acid was used. If it was laid aside, and some
bland application was made, however, keratoplasia would
rapidly follow. This action led me to retain it in the pyro-
gallic collodion, as it occurred to me that its presence
might have the effect of diminishing, or perhaps preventing,
the formation of epidermic scales on the psoriatic plaques
or lesions, thus allowing the pyrogallic acid to act more
directly upon the affected cutis.
In using the pyrogallic collodion, the patient should be
directed to first remove all the scales by taking a warm bath.
After drying the body carefully, the solution should be
freely applied to the lesions, the application extending one
fourth or one half an inch beyond the edges of the psoriatic
spots. This can be done by using a moderately stiff, bushy
brush. Care should be taken that the lesions are com-
pletely covered with the solution, and the parts which have
been painted should remain exposed until they are perfectly
dry. A renewal of the application may be made every day
if desired, but I have found it quite sufficient to repeat it
every second or third da}7. Removal of the collodion still
adhering to the skin is of course necessary previous to each
fresh painting, since it is advisable to treat the psoriatic
lesions, and not the old coats of collodion covering them.
In all the cases of psoriasis in which the pyrogallic col-
lodion has been used there has been no soiling of the patient's
linen. After the application has dried, if it were not for
the color, which gradually darkens, its presence would not
be noticed. I have not seen any dermatitis follow its
proper use in any case. One patient, however, for whom
the solution was prescribed as an application for a spot of
herpes tonsurans, applied it industriously three times daily,
though otherwise instructed, and, as might have been ex-
pected, caused a dermatitis to light up around the lesion. In
no case have I seen any pigmentation remain after the cure
of the psoriatic lesions ; the surface to which the pyrogallic
collodion had been applied differed in no way in appear-
ance from the surrounding skin. If the solution is improp-
erly used, however, and dermatitis lighted up, pigmentation
may easily occur ; consequently it is necessary to be care-
ful not to apply it so often that undesired results may
ensue.
The results obtained in treating psoriasis with the pyro-
gallic collodion have been in every way satisfactory. A
great change could be seen in the lesions after a few appli-
cations. There was an absence of scales and a diminution
in the hyperemia, and the plaques and spots appeared less
elevated. The time which was required in curing the
psoriasis by means of this solution has naturally varied ac-
cording to the extent of the disease and the length of time
which it had existed. Any rule in regard to it could scarce-
ly be made. The quickest results which I have obtained
were in psoriasis guttata, and the slowest in a case of psori-
asis nummularis of long standing. In cases where the
eruption is universal, or nearly so, it is of course advisable
to treat the various portions affected seriatim. The results
will be just as satisfactory, only the time required will be
longer.
In one other form of skin disease, herpes tonsurans, I
have used this solution of pyrogallic acid, and with most
gratifying success. Its effect upon the lesions has been
surprising, two applications having been sufficient in the
majority of cases to effect complete cure.
In addition, I can only say that I trust this combina-
tion of pyrogallic acid and collodion will obtain a greater
recognition for the acid than it has heretofore enjoyed with
us, and I hope it will prove as satisfactory to the members
of the profession as it has to me in both hospital and pri-
vate practice.
SOME OBSERVATIONS WITH REFERENCE
TO CHOLEROID A L VINE DISCHARGES.
By FRANK S. BILLINGS,
PATHOLOGIST TO THE NEW YORK POLYCLINIC.
On the 22d of June, Dr. J. H. French, of the Fourth
Medical Division, Bellevue Hospital, sent some material for
examination to the Patho-biological Laboratory of the New
York Polyclinic.
The following remarks accompanied the material :
" The specimen is from a patient admitted last night
Sept. 5, 1885.] JARVIS: NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS.
259
suffering from acute gastro-intestinal catarrh ; discharges
very frequent,' accompanied with emesis ; great thirst."
Examination of material :
It had the usual appearance of rice-water stools, almost
inodorous, and was full of yellowish-white flocculi.
Reaction: Strongly acid.
Microscopical examination of the flocculi revealed the
presence of various forms of cocci, diplo- and strepto-cocci,
and bacilli, but absolutely nothing that could be called a
comma.
As it was late in the evening, the material was at once
corked and placed in an ice-chest, very near the ice. It was
our intention to filter it very carefully in "the morning and
then sterilize, and to use this material in its natural acid
and a reduced alkaline condition as a cultivating medium
for the Koch and Finkler commata.
In this regard I made an unexpected and perhaps excusa-
ble error, which is, however, practically, quite suggestive.
The reaction of the material should have been taken the
next morning, and it should have been filtered before a
microscopic examination was made. On the contrary, we at
once filtered it, and threw the residue away.
We next tested the reaction. It had become alkaline
of itself.
The questions now arise-:
1. What caused this change in reaction?
2. Would it have occurred intra vitam in the same pa-
tient had he not improved and recovered ?
3. Would comma bacteria have then appeared? (The
Finkler comma has not yet been proved to have universal
diagnostic value even for cholera nostras, as can be accepted
for that of Koch with regard to cholera asiatica.)
4. Were the germs of any form of comma bacteria pres-
ent, and would they have developed in the mass had it been
allowed to stand in an ordinary temperature after it had
become alkaline; or, in other words, were there comma germs
in it, intra vitam, needing only an alkaline condition of the
intestinal contents for their development ?
5. Aside from all known connections with comma bac-
teria in the alvine discharges of acute catarrhal diseases,
these experiments indicate still another question which may
have important clinical bearings, viz. : If in such cases the
discharges suddenly become alkaline instead of acid in their
reaction, is it not an indication of a fatal termination, or, at
least, of a most questionable prognosis ? If, on the other
hand, the discharges become acid after having had an alka-
line reaction, may it not indicate a favorable change in the
disease ?
Both of the comma bacteria develop spores at certain
periods of their existence.
To prove that the filtered material, which contained all
its original elements in solution, and had acquired an alkaline
reaction, was a suitable medium for the development of these
commata, it was boiled several times in appropriately closed
test-tubes, then allowed to stand for forty-eight hours in
the ordinary — extraordinary — heat of the laboratory. It
remained absolutely clear and amber-colored.
1. The tubes were then carefully inoculated with purely
cultivated Koch and Finkler commata.
2. In twenty-four and forty-eight hours there were indi-
cations of their development in the opalescence of the media.
8. Gelatin tubes were again inoculated from these and
both commas developed in the recognized manner.
These very few experiments, but still sufficient in num-
ber, prove the conclusions so well known of Koch and
others with regard to the biological necessities of the two
commas.
They also show that the discharges from ordinary chol-
eroid cases have, in their serum or fluid, every requisite for
the development of these bacteria as soon as the intestinal
contents assume an alkaline character, or it is artificially
produced, as has been also shown by animal experiments.
The attention of clinicians is called to these points.
It certainly is not out of place for me to say that we
are prepared to supply boards of health, hospitals, or phy-
sicians with any of the forms of gelatin or blood-serum de-
sired for experiments, or to conduct any examinations that
may be desired. We are especially desirous of obtaining
material for study as above described.
CATARRHAL AFFECTIONS OF THE
NASAL PASSAGES
AS A CAUSE OF
PULMONARY PHTHISIS,
WITH SPECIAL REFERENCE TO THE QUESTION OF
HEREDITY*
Br WILLIAM CHAPMAN JARVIS, M. D.
The aetiology of pulmonary tuberculosis, a subject
always replete with interest to the clinical investigator, has
naturally received a deeper significance since the discovery
of the Bacillus tuberculosis. Despite, however, the positive
character of Koch's results, there remains, according to his
own admission, much yet to be learned concerning the prae-
tubercular conditions which determine the development of
the tubercle bacillus.f These conditions, variously and oft-
times vaguely referred to by such terms as tubercular dispo-
sition, predisposition, heredity, environment, etc., it would
appear, are the principal avenues through which this mo-
mentous question, affecting the lives of so many thousands
in our crowded city and elsewhere, is to be approached.
Several years ago, while studying the cause and compli-
cations of nasal diseases, my attention was attracted to the
co-existence of bronchial with nasal catarrh, and somewhat
later to the association of nasal disease with pulmonary
phthisis.
These earlier impressions did not assume the shape of
convictions until the reliable evidence I am about to present
for your serious consideration was forthcoming.
. In view of the light already thrown upon the question
of the aetiology of tuberculosis through Koch's bacillary in-
vestigations, I have deemed it profitable to review some of
the evidence he has offered us concerning the disposition
and predisposition to phthisis.
As regards the question of the physical conditions fa-
* Read before the American Cliruatological Association, May 27,
1885.
\ " Mittheilungen aus dem kniserlichen Gesundheitsanite."
JARVIS: NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS. [N. Y. Med. J
260
vorable for the development of bacilli, we are informed by
Koch that pent-up secretions, removal of the protective
epithelia of the bronchi, abrasions, etc., are to be considered
the proper soil — the " geeignete Boden" — for the lodgment
and growth of the deadly tubercular plant. Now, these
conditions will be recognized as the common results of ca-
tarrhal inflammation of the upper and lower air-passages.
One or more of them are frequently observed in nasal ca-
tarrh, and may be also associated with catarrhal phthisis
when taken in the popular sense of the term as taught to
us by Dr. Alfred L. Loomis.
In certain cases we find pulmonary tuberculosis rapidly
following in the train of a catarrhal bronchitis, while others
will, apparently, resist the inroads of the bacillus for many
years.
In treating my subject I shall begin with the nares and
endeavor to distinctly trace the effects of nasal catarrh upon
the larynx, and then in turn explain the relation of the
resultant laryngeal disease to bronchial catarrh, catarrhal
phthisis, and, finally, pulmonary tuberculosis.
The relations of the nostrils to the lungs is so intimate
that we are not surprised to find Koch involuntarily ad-
dressing his attention to the nose for a partial solution at
least of the question of the etiological relations of the ba-
cillus to pulmonary tuberculosis, with the remark, " Air in-
haled through the nose is deprived of disease-germs, and
nasal respiration, therefore, constitutes a positive protection
against infection by reason of the retention of the infec-
tious material by the nasal mucous membrane." Conspicu-
ous among the complications traceable to nasal catarrh,
and bearing upon the question of the causation of pulmo-
nary phthisis, is chronic irritative hypercemia of the larynx.
I can not at present enter into a description of this affec-
tion, or fully explain how it is brought about by the entrance
of nasal mucus into the larynx. I called especial attention
to this condition in a paper read before the American La-
ryngological Association, session of 1881, to which I must
refer you.*
This affection is usually observed as a peculiar red dis-
coloration of the normally pearly white vocal cords, and, when
found, constitutes an excellent guide for the determination of
the amount of congestion of the general laryngeal mucous
membrane. Chronic hyperaemia of the larynx frequently de-
velops attacks of acute catarrhal laryngitis, and this affection
in turn often involves the tracheal and bronchial mucous
membrane by inflammatory extension. In other words,
recognizing the larynx, with certain modifications, as the up-
per portion of the lungs, catarrhal inflammation of this organ
clearly constitutes a menace to the integrity of the entire
pulmonary tract. The laryngoscopic study of the patho-
logical processes concerned in the production of laryngeal
hyperaemia and its common sequela — laryngitis — is, there-
fore, required to throw light upon the pulmonary diseases
following in its wake.
Nasal stenosis and defective nasal drainage are the two
most important indirect agents concerned in the production
of this affection. The manner in which these intra-nasal
disturbances lead to laryngeal and lung complications is
principally by habitual mouth-breathing, the irritating ac-
tion of nasal mucus in the larynx, and inflammatory exten-
sion from the posterior nares.
The part played by nasal mucus as an aetiological fac-
tor in the production of laryngeal and pulmonary disease
is well pronounced and very important. The constancy
with which chronic irritative hyperaemia of the larynx oc-
curs as a result of chronic nasal catarrh encouraged me to
make the statement that the simple discovery of this pecu-
liar congestion was, as a rule, sufficient evidence of the ex-
istence of a chronic nasal catarrh.
The manner in which chronic hyperaemia of the larynx
is induced through defective nasal drainage is exceedingly
simple, and [is best understood by carefully studying the
direction of the several anatomical planes of the upper air-
passages. I will refer you to a paper read by me before the
New York Academy of Medicine, in which is given a detailed
description of this system of drainage.*
I may simply state in passing that the disturbances to
nasal drainage originating from a nasal catarrh prevent the
natural disposition of nasal mucus, and, consequently, permit
it to enter the larynx. Now, nasal mucus in the larynx is a
foreign body, and as such invariably gives rise, by prolonged
irritation, to a familiar train of signs and symptoms. Fore-
most among the signs stands, as I have already pointed out,
chronic irritative hyperaemia of the larynx. The larynx
naturally resents the invasion of its territory by irritating
nasal discharges, and we have, as one of a number of well-
marked symptoms, a constant inclination to " clear the
throat." This act in itself may constitute an additional
irritant by the rasping effect of the effort upon the vocal
cords. The part played by habitual mouth-breathing as an
excitant of laryngeal disease is simply that resulting from
the absence of those conditions so essential for the purifica-
tion and preparation of the respired air, and attributable to
prolonged nasal stenosis.
Having briefly presented the most conspicuous causes
which serve to account for catarrhal disease in the larynx,
the next step would naturally be to study the nasal compli-
cations responsible for the existence of the laryngeal affec-
tion.
Among these may be mentioned deviation of the nasal
septum, turbinated hypertrophies, polypi, adenomata of the
vault of the pharynx, etc. The proper consideration of
either one of these conditions, taken alone, would cover
many pages. I shall, therefore, be compelled to entirely
omit the consideration of some, and only briefly accentuate
those most commonly concerned in the production of laryn-
geal and pulmonary disease.
Hypertrophy of the turbinated tissues is an almost inva-
riable concomitant of the moist forms of nasal catarrh. It
may stand either alone or, aa is commonly the case, exist
as the result of a deviated septum. The co-existing mouth-
breathing, hypersecretion, and disturbed nasal drainage will,
of course, be governed by the location and amount of the
turbinated hypertrophy. Passing promptly to the consider-
* " Archives of Laryngology," vol. iii, p. 148.
* " Medical Record," March 14, 1885.
Sept, 5, 1885.] JARVIS: NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS.
ation of the second condition, the deviated septum, we are
at once confronted by the most active and common agent
concerned in the production of pulmonary and laryngeal
disease. This condition differs from turbinated hypertro-
phy in being both a cause and result of catarrhal inflamma-
tion. Its existence, furthermore, implies the co-existence
of a turbinated hypertrophy, barring, of course, recent trau-
matic deviations and extra-nasal distortions of the septum.*
I have already had occasion to explain how a deviated sep-
tum, through pressure irritation, excites catarrhal inflam-
mation.f Its action may be, to employ a homely example,
compared to that of a shoe-button impacted in the nostril.
The deviated cartilaginous spur, like this familiar foreign
body, presses against the exceedingly sensitive surfaces of
the turbinated tissues, invariably exciting and keeping up a
certain amount of inflammatory action.
Thus we have a system of reciprocal irritation provok-
ing and prolonging a nasal catarrh. For want of a better
expression, I have called this pressure irritation, and I trust
the term may recall to your mind the pathological process
it indicates when employed in this paper.
The role played by the turbinated tissues and septum in
the production of rhinitis hypertrophica was noted by me
in a paper read before the American Laryngological Asso-
ciation, session of 1880 ; and the serological relation of the
nasal septum to diseased turbinated bodies was also satis-
factorily demonstrated by Dr. Harrison Allen, though in a
way differing from my own, in the same year.
Having determined the serological significance of the
deviated septum in nasal catarrh, for a more detailed de-
scription of which I must refer you to my earlier papers
on this subject, add another factor which serves in turn to
account for the deviated septum, and requires a brief con-
sideration— namely, heredity.
The term heredity, usually furnishing much material
for uncertain speculation and little opportunity for satisfac-
tory demonstration, has, in this connection, assumed a more
definite meaning by reason of much corroborative testi-
mony always at hand.
This evidence has convinced me that the deviated sep-
tum is frequently transmitted from parent to child.
In 1882, while engaged relieving the sufferings of a
young woman, brought on by a congenital occlusion of the
nares, my attention was attracted to an abnormal contrac-
tion of the superior maxillae. In reporting the case I laid
great stress upon the possibility of the chronic coryza and
turbinated hypertrophies being associated with this condi-
tion as cause and effect.J Since that time, by careful in-
vestigation and comparison, I have been enabled to supply
the necessary links in a chain of evidence which has demon-
strated that one of the most common causes of catarrh is
discoverable in the conformation of the hard palate. This
peculiar malformation I find to be transmitted from parent
to child with remarkable regularity, and its intelligent recog-
nition and proper appreciation enables one to most satisfac-
* See "Archives of Laryngology," 1882, vol. iii, p. 300.
f Ibid., vol. ii, p. 147.
% Ibid., vol. iii, p. 108.
26 L
torily account for a large number of catarrhal disturbances
in the upper air- passages.
In these cases we find that the superior maxillary bones
are not only contracted, but are likewise elevated, abnor-
mally increasing the depth and diminishing the diameter of
the roof of the mouth. The vertical measurement of the
osseous nares is naturally more or less affected by the en-
croachment of the elevated hard palate, and the nasal sep-
tum, as a consequence, is bent laterally, as exemplified in
the diagram, Fig. 1, A representing the normal septum and
maxillary arch, and B the abnormal.
A. B.
Fig. I.
These plaster impressions, kindly presented to me by
Dr. Eddy, nicely illustrate this peculiar palatine formation.
They were selected from among thirty other plaster casts
as the only two in which I could positively pronounce the
existence of a chronic nasal catarrh. The doctor, on refer-
ring to the name of the subject, found that both belonged
to the same individual — a patient he had referred to me
several years before for a severe chronic coryza, and the
only one out of the whole number of casts. On comparing
this plaster impression, Fig. 2, with the normal palatine arch,
you will discern certain well-defined differences. The dis-
Fio. 2.
tance between the alveolar ridges is much greater in the
normal specimen. The transverse diameter of the abnormal
specimen is not only smaller, but its surface is markedly ir-
regular. The maxillary arch may be considerably higher
than this normal specimen, and yet not constitute a patho-
logical condition. No two maxillary arches are exactly
alike, and some exhibit an elevation easily mistaken for a
deformity. The important distinction to bear in mind is
the abrupt elevation along the line of the median rhaphe.
When such a condition is observed, we may at once look
for, and, in my experience, invariably discover, a correspond-
ing deviation of the septum. This condition, furthermore,
262
JARVIS: NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS. [N. Y. Med. Joi.k.,
is found associated with a chronic coryza. ' Indeed, I hold
it to be possible in certain cases to diagnosticate the exist-
ence of a chronic nasal catarrh by the simple examination
of the roof of the mouth, or, what amounts to the same
thing, by inspecting an impression in wax or plaster, from
any part of the world. After having ascertained the con-
genital character of this nasal abnormality, the next step
was an endeavor to account for its existence. In tracing
this peculiar formation to ite hereditary origin, I was greatly
assisted by instituting a comparative study of the external
nose, and particularly the persistence of certain types in the
same family.* By employing a, similar method of reason-
ing to the internal configuration of the nares, I have been
able to trace the peculiar conformation back to a common
parental origin. This condition occurs as an hereditary
manifestation with great constancy. Once the peculiar
nasal type of the parents is recognized, its modifications in
the children are easily determined.
It would appear that abnornal contraction of the nares
is likely to be associated with intellectual enlargement of
the skull in certain families, a fact which may serve to
account for the tendency to phthisis attributed by some
observers to severely studious or sedentary habits.
It is well known that a marked increase in the dimen-
sions of the cranial dome is apt to be accompanied by a
contraction of the osseous frame-work of the face. If it
were convenient I might cite a number of interesting exam-
ples, carefully collected by me, to prove the correctness of
this view.
Through Dr. L. J. B., referred to me by Dr. P. A. Mor-
row, my interest in the elevated arch and the septum of
heredity received a fresh impulse.
Fig. 3 is a reproduction of the doctor's palatine profile.
He creditably appreciated the significance of the high-
pitched arch, and directed my attention to the peculiar for-
mation of his own. The co-existing deviation of the septum
was very well marked, and there were several other interest-
ing features connected with this physician's condition.
I might mention, for instance, the unique occurrence, as
far as I know, of a periodical perspiration over a circum-
scribed area, above the left malar prominence, and around
the neighboring portion of the cheek.
There was an extensive general deviation of the septum
to the left, and it was fair to presume that this peculiar per-
spiratory anomaly was due to prolonged intra-nasal pressure
exerted by the deflected structure.
The prompt disappearance of this annoying symptom
after removal of the offending tissues confirmed the correct-
ness of this view. The doctor, although a life-long sufferer
with nasal catarrh, was so much benefited by surgical treat-
ment as to pronounce himself, in certain respects, a differ-
ent man. Free nasal respiration through the left nostril
was, for the first time in his life, made possible.
The following extract from his family history is of in-
terest as regards the question of heredity : His father, a
physician now deceased, was all his life-time annoyed by
* " It is said by Ribot that, of all the features, the nose is the one
which heredity preserves best." — "Hereditary Traits," Richard A. Proc-
tor.
a persistent coryza and throat trouble. On comparing the
doctor's photograph with an oil-painting of his father, a re-
Fio. 3.
semblance in respect to the shape of the nose and forehead
is sufficiently well marked to challenge the attention of even
a casual observer. Furthermore, I ascertained, from a
member of the family, that his grandfather, also a physician,
looked like his father and was afflicted with a catarrhal
affection.
I have selected from my case-book a few life-sketches,
which will aid me in explaining what I mean by hereditary
Fig. 4.
deviation of the septum. This, Fig. 4, was copied from the
life-sketch of a boy, aged fourteen, referred to me by Dr.
Sept. 5, 1885.] JARVIS : NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS.
263
A. W. Berle, of New York, and the next drawing, Fig. 5,
was taken from the father of the lad. The hard palates of
both were markedly contracted and elevated. The father
had bilateral deviation of the septum with life-long nasal
catarrh, and the son was referred to me for relief from the
same trouble.
A cross-section of the elevated and contracted hard
palates is shown in Fig. 3, where No. 3 represents the father
and No. 4 his son.
These tracings were obtained by taking a wax impression
of the roof of the mouth, then reproducing the deformity
in plaster of Paris, and dividing the casts thus obtained
with a fine saw, in a transverse direction. The divided
fragments were then simply laid upon a piece of paper and
outlined.
You may be able to distinguish a slight resemblance in
their shape, when compared with each other, this similarity
being rendered more distinct by their dissimilarity with the
other arches.
An idea of their abnormal divergence from the true
type may be obtained by comparing the two arches with
No. 1, taken from a plaster cast exhibiting an unusually flat-
tened and expanded hard palate, and selected as an extreme
illustration of the kind.
Returning to the sketches (Fig. 4) you observe the car-
tilage of the son's septum is deviated to the left as a local-'
ized nodular projection, almost on a level with the floor of
the nose.
Fio. 5.
The father's septum (Fig. 5) was also thrown to the left,
but, in the form of general deviation, situated superiorly in
the nostril, the inferior-anterior edge of the septum being
deflected into the right nostril in a manner similar to the
son's.
It may be worth noting that when the lad was first
brought to me I sought the hereditary origin of his devi-
ated septum in the mother's nose, with a negative result;
and yet, unwilling to be adjudged guilty of an erroneous
conjecture, I persuaded the mother to induce her husband
to visit me, and proved the correctness of my inferences as
just described. The removal of the deviated cartilage from
the boy's nostril was followed by an excellent result. This
drawing (Fig. 6) shows the nose of a son aged twenty-
two, and next to it (Fig. 7) that of the father. They are
copied from life-sketches. You observe that both septa
are generally deviated in the same direction. Both were
severely afflicted with a life-long coryza.
Fig. 6. Fig. 7.
Fig. 3, Nos. 5 and 6, exhibit transverse tracings of the
father's and son's hard palates in the order mentioned. The
point of highest elevation, it will be observed, is toward the
nostrils into which the septa were deflected. The father,
an old man, had become reconciled to his lot in life, although
the extremely harassing character of his complaint made me
marvel at this decision.
His bitter experience had the happy effect of making
him alive to his son's life-interests. Directing our attention
again to the sketches (Figs. 6 and 7 ), you observe the cartilage
of the septum is conspicuously inclined to the left in both
father and son. The father's septum (Fig. 7) exhibits, how-
ever, a greater degree of deflection, the respiratory space
being reduced to a useless slit.
You may be able to distinguish a similarity in the shape
of the external nose. The father, although a sufferer for
many years with bronchitis and asthma, might be consid-
ered, under the circumstances, tolerably well developed and
preserved. The son, on the contrary, also complaining of
lung trouble, was stunted in stature, emaciated in appear-
ance, with a haggard face and an unhealthy skin.
I operated upon the young man, removing two antero-
inferior turbinated hypertrophies, and shaving off the sep-
tum for the whole length of the triangular cartilage, ex-
cising also a small portion of the anterior border of the
vomer. Fig. 8, taken from a life-sketch, exhibits the left
- - ^/J""''"~^.';;ifl*».
Fig. 8.
nostril after excision of the deviated structures. I em-
ployed my transfixion needles and ecraseur for the removal
of the redundant turbinated tissues, using my fenestrated
cartilage forceps, tubular-spring forceps, and rongeur bone
scissors for leveling the septum.
The subject of this illustration (Fig. 9) was afflicted
264
JARVIS: NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS. [N. Y. Med. Jodh.,
with, and cured by me of, an extensive osseo-cartilaginous
deviation of the septum. The drawing was taken from a
Fio. 9.
life-sketch, and the history of this individual throws much
light upon the origin and growth of the septum of heredity,
fou may catch my meaning when I inform you that I was
enabled to correctly diagnosticate, or, more accurately speak-
ing, infer, through this patient, the general condition of the
nostrils and health of all his brothers, four in number, and
his father. In this family the nasal asymmetry was very
well marked, the septum in one instance being deviated to
such an extent as to disturb the external symmetry of the
nostril. All the young men seen by me, three in number,
possessed the paternal nasal type and palatine arch in an
exaggerated form. All have suffered with nasal catarrh
dating far back in the memory of the family, and I am in-
formed that the absent son, not yet examined by me, is
severely afflicted with the same complaint. The patient, an
engineer by profession and a very intelligent individual,
referred to me by Dr. J. L. Corning, stated that a physi-
cian informed him that his condition was due to a scrofulous
taint, probably inherited from his father. I failed to dis-
cover the slightest trace of scrofula in any of these indi-
viduals.
The cases I have just cited are not to be considered, as
regards their immediate condition, phthisical in character ;
they have simply been submitted as excellent examples of
the influence of heredity as a determining factor in the pro-
duction of nasal disease, and as such must assist us in inter-
preting the same conditions when found in phthisis.
The testimony which I have just submitted, re-enforced
by much more which I could, but can not now conveniently,
offer, affords, to my manner of thinking, excellent proof of
the intimate association of a high-pitched hard palate with
a deviated septum, and their transmission from parent to
child.
The relation of traumatic deviation of the septum to
nasal catarrh and catarrhal phthisis is not so important as
that of the hereditary variety ; still it possesses many points
of interest did time permit their consideration. Traumatic
deviations of the septum, especially in those not predis-
posed to phthisis, are not likely to be followed by pulmo-
nary tuberculosis. It should be borne in mind that the two
conditions may be associated. The differentiation, however,
as I shall have occasion to explain, is, as a rule, easily accom-
plished.
Although the cases of induced coryza just cited by me
were of the hypertrophic variety, it should not be inferred
that rhinitis atrophica may not be developed by the devi-
ated septum.
Deviations determining the existence of atrophic coryza
are general in character, and the dryness is evidently due to
the excessive drain upon the mucous follicles resulting from
the prolonged passage of air through a single nostril.
As an example of pulmonary phthisis following in the
train of a rhinitis atrophica, I may be permitted, in an
effort to make my meaning clearer, to precede my report of
cases with a brief reference to a patient, aged thirty, treated
by me at the University College Dispensary in the winter
of 1882.* I found the nasal septum in this individual most
extensively deflected, the deviation being osseo-cartilaginous
in character. An atrophic rhinitis existed as a result of the
nasal disease, both nasal chambers being inordinately en-
larged through long-standing atrophic processes. Large and
firm masses of muco-purulent matter clung to their smooth
walls. These dry crusts were constantly detached and pre-
cipitated into the throat, irritating and inflaming the larynx.
The patient was harassed and enfeebled by the unremit-
ting efforts required to free his throat and larynx from these
suffocating crusts. The atrophic processes had reached the
pharynx, where, in the form of a pharyngitis sicca, it pre-
sented a dry patch, which obstructed the downward flow of
the scanty nasal mucus, collecting it in the shape of sticky
incrustations just behind the velum.
A laryngoscopic examination showed the true cords to
be deeply injected and the contiguous structures inflamed
by reason of the constant irritative action of the nasal in-
crustations which had found lodgment there.
The patient was extremely emaciated, weak, and miser-
able through the constant efforts required to free the
throat from inspissated irritating discharges. There were
night-sweats and the usual symptoms of advanced phthisis.
An examination of his lungs, conducted by Dr. Moore,
assistant to th£ Department of Medicine at the University
Dispensary, and myself, revealed the existence of advanced
destructive processes, as evidenced by the presence of cavi-
ties, a profusion of fine crepitant rales, and other famil-
iar signs of the last stage of a rapidly progressing pulmo-
nary phthisis. It was clear that the patient had reached a
point where fatal prostration was imminent, and for an im-
portant reason we considered it best to advise him of his
hopeless condition. Hoping to delay the fatal issue as
much as possible, the patient found it convenient to accept
the invitation of relatives in Florida, and so passed from
under my observation.
The points of interest to us as regards this case, briefly
summed up, are the history of a long-standing nasal ca-
tarrh and the manner in which it developed a pulmonary
phthisis. That the nasal catarrh preceded the tubercular
disease is proved by two features of the affection — namely,
a deviated septum, osseo-cartilaginous in character, not
associated with external nasal disfigurement, and therefore
non-traumatic but hereditary, and a rhinitis atrophica.
Either of these pathological conditions would indicate
the chronicity and persistency of the nasal catarrh, and
* See also No. I of illustrative cases.
Sept. 5, 1885.J
therefore prove that they must have preceded the pul-
monary disease ; and in this, and in similar cases, we are
afforded excellent evidence of the occurrence of the pul-
monary lesion as a secondary complication to the catarrhal
processes. .
(To be concluded.)
The Principles of Ventilation and Heating, and their Practical
Application. By John S. Billings, M. D., LL. D. (Edin.),
Surgeon, U. S. Army. New York : The Sanitary Engineer.
1884. Pp. 216. [Price, $3.]
Dr. Billings's book is a most scholarly exposition of the
subject of which it treats. The author refers very modestly to
his work in the opening sentence as if it were a short pamphlet
which he had thrown off for the instruction of amateurs, but it
is soon evident on turning over its pages that he enters into the
subject iD a thoroughly scientific and exhaustive manner. The
book is divided into twelve chapters, the first three of which
deal with the scientific aspect of the question, while the remain-
ing chapters are devoted to the practical application of scien-
tific facts. The subject of ventilation occupies most of the
space. There are seventy-two illustrations, principally repre-
senting plans of public buildings and sanitary apparatus.
Dr. Billings's style is clear and pleasing, and his work is an
extremely useful one to all who are interested in this branch of
sanitary engineering.
The Middlesex Hospital. Reports of the Medical, Surgical, and
Pathological Registrars, for the Year 1883. London: H. K.
Lewis, 1885. Pp. 544.
This volume contains mucb interesting matter, although the
method of tabulating the cases is, in our judgment, not the best.
It is divided into a medical and surgical report. The former
deals only with typhoid fever, diseases of the nervous system of
special interest, and malignant growths ; the latter with can-
cer of the uterus, breast, tongue and mouth, lower lip, rectum,
miscellaneous cancers, rodent ulcer, sarcoma, non-malignant
tumors, infectious diseases, strangulated hernia, and compound
fracture. In each class the cases are arranged in a tabular
form, which, although there is something in favor of such a
method of registration, leads to much space being sacrificed,
and makes difficult and unsatisfactory reading.
There is no general summary, and but a slight attempt at
any practical deduction. The labor of preparing such a report
must have been very great, while this arrangement detracts
much from the value of the work. We trust that in a future
volume the editors will do away with the strict tabular arrange-
ment.
BOOKS AND PAMPHLETS RECEIVED.
Cholera: its Origin, History, Causation, Symptoms, Lesions,
Prevention, and Treatment. By Alfred Stille, M. D., LL. D.,
etc. Philadelphia: Lea Brothers & Co., 1885. Pp. 164.
A Treatise on Epidemic Cholera and Allied Diseases. By
A. B. Palmer, M. D., LL. D., Professor of Pathology, Practice
of Medicine, and Clinical Medicine in the College of Medicine
and Surgery in the University of Michigan, etc. Ann Arbor :
Register Publishing House, 1885. Pp. 224.
Lectures on the Diagnosis of Diseases of the Brain, delivered
at University College Hospital, by W. R. Cowers, M. D., F. R.
265
C. P., Assistant Professor of Clinical Medicine, etc. Philadel-
phia: P. Blakiston, Son, & Co., 1885. Pp. viii-246. [Price,
$2.]
Inebriism; a Pathological and Psychological Study. By T.
L. Wright, M. D., etc. Columbus, O. : William G. Hubbard,
1885. Pp. 222.
A Manual for Hospital Nurses and others engaged in attend-
ing on the Sick. By Edward J. Domville, L. R. C. P. Lond.,
M. R. C. S. Eng., etc. Fifth Edition. Philadelphia: P. Blakis-
ton, Son, & Co., 1885. Pp. 96.
Medical Society of the State of Tennessee. Transactions
1885.
Ninth Annual Report of the Managers and Officers of the
State Asylum for the Insane, at Morristown, N. J.
History of the Clamp-Suture of the late Dr. J. Marion Sims,
and why it was abandoned by the Profession. By Nathan
Bozeman, M. D., etc. [Reprinted from the "Transactions of
the American Gynaecological Society."]
Submucous Laryngeal Haemorrhage. By Ethelbert Carroll
Morgan, M. D., etc., Washington. [Reprinted from the " Medi-
cal Record."]
The Influence of Cocaine, Atropine, and Caffeine on the
Heart and Blood-Vessels. By H. G. Beyer, M. D., M. R. 0. S.,
etc. [Reprinted from the " American Journal of the Medical
Sciences."]
Suersen's Obturators ; their Construction and Uses. By Dr.
Th. Weber, Helsingfors, Finland. [Reprinted from the " Inde-
pendent Practitioner."]
The College of Medicine of the University of Southern Cali-
fornia. 1885.
The Treatment of Opium Addiction. By J. B. Mattison,
M. D., etc. New York : G. P. Putnam's Sons, 1885. Pp. 49.
[Price*, 50c]
Hunterian Lectures, 1885. The Anatomy of the Intestinal
Canal and Peritonaeum in Man. By Frederick Treves, F. R. 0.
S., etc. London : H. K. Lewis, 1885. 4to, pp. 6*6.
The History of a Legislative Shame.
LETTER FROM CINCINNATI.
The Ohio Profession and the International Medical Congress. —
Dr. Lane's Case. — Cincinnati Physicians as Artists.
Cincinnati, August 31, 1885.
Under date of August 20th, Dr. William Morrow Beach,
president of the Ohio State Medical Society, issued a call for
"a conference of the leading physicians" of the State, to be
held at Columbus on the 27th inst., to take action relative to
the International Medical Congress. The letter alludes to the
present outlook and says that " some steps must be taken,
promptly and energetically, to bring the existing factions into
harmony." The president also says: "It has seemed to me
the part of wisdom for Ohio, which is an important and pivotal
State, to take the initiative." The object of the meeting was to
" offer suggestions or give instructions to our State representa-
tive" in the enlarged committee for the guidance of his action
at the New York meeting on the 3d prox. The letter con-
cludes: "If you can not come, send a proxy, as this should be
a thoroughly representative meeting. The following gentle-
men, among others, have been especially invited to be present,
although any others who are interested will be cordially wel-
comed." Then follow the names of thirty-six gentlemen,
BOOK NOTICES.— CORRESPONDENCE.
266
CORRESPONDENCE.
[N. Y. Med. Jocb.,
among which occur those of all the physicians, or, at least,
nearly all of those in Ohio who resigned from the new organi-
zation.
The wording of the call was certainly unfortunate, if the
whole movement was not a faux pus. Those who had resigned
surely could not be expected to participate in a meeting the
object of which was to harmonize them with a faction from
which, by their own acts, they had dissociated themselves,
while the equivocal welcome promised to those not " especially
invited " kept the mass of the profession away. At any rate,
of the several thousand physicians in Ohio but enough attended
the meeting to allow a maximum vote of twenty-three! Of
those voting there were but twelve from outside of Columbus!
This "representative meeting," held in the hub city of the
" pivotal State," proceeded to business by very properly dis-
missing the reporters of the secular press. A committee, con-
sisting of Dr. Fowler, Dr. Franklin, Dr. Greenleaf, Dr. Bald-
win, Dr. Larimore, and Dr. Vance, was appointed to draft
resolutions. After an hour and a half a report was presented
in purport as follows :
First. — That the Ohio delegate use his influence to harmo-
nize existing difficulties, accept no resignations, but insist that
all officers and committees perform their work toward arrang-
ing for the International Congress. [Carried.]
Second. — That geographical boundaries be not considered in
making appointments of officers and committees, but that men
of ability, no matter where resident, be made the appointees.
[Carried.]
Third. — That no code questions be considered in the organi-
zation of the Congress. [Amended by striking out " organiza-
tion" and inserting "membership," after which it was adopted
—19 to 3.]
Fourth. — That the enlarged committee (of 46) at its* New
York meeting reinstate all those whom it had dropped from the
list prepared by the original committee (of 8), and from the
list as thus increased, and with such additions as they might
see fit to make, redistribute the offices. [Lost, 10 to 13.]
It is now known that, were the vote on the last resolution
to be taken over again, the result would be different, as its real
purport was not comprehended by the meeting. I have it, ex
cathedra, that the object of those framing the resolution and
reporting it was that the men proposed by the old committee
and to be now reinstated by the new committee should all be
officers, but that their various offices should be determined by
the enlarged committee, the idea being to admit the new-code
men but to relegate them to the lowermost rooms ; i. e., to the
"councils" of their respective sections. The word "reinstate"
led the meeting to infer that the proposition was that the " re-
instated " were to have their former " offices," which was not
contemplated.
The net result of the meeting, so far as anything of impor-
tance is concerned, was, therefore, the passage of a resolution
instructing the delegate from Ohio to vote for a proposition to
allow the new-code men to come into the Congress as members.
To what exteDt this result will tend "to bring the existing fac-
tions into harmony," particularly when viewed by the light of
the inside facts which I have given, remains to be seen. But,
small and far from " representative " as was the meeting, its
conclusions were a slap in the face to the American Medical As-
sociation and a triumph to the new-code men. The repudia-
tion of the " geographical-distribution " idea was an intimation
to the National Association of its asininity ; the recommen-
dation that new-code men be admitted to " membership " in
the International Congress conceded their importance to the
scientific feature of that gathering; and when it was seriously
proposed to capture them, even at the expense of Jesuitical
methods, it was as much as saying, " They come high, but we
must have them." At any rate, viewing the meeting only in
the light of its action, it is to be taken as one of the evidences
of " weakening " on the part of those who, in the main, have
been in sympathy with the action taken at New Orleans.
Apropos of the International Congress imbroglio it may be
stated that the deposing of Dr. Levi C. Lane, of California,
from the vice-presidency of the Congress is exciting considera-
ble comment in this State. Dr. Lane is a native of southwest-
ern Ohio, and is to-day one of the conspicuous successes among
the sons of the " Buckeye State." The product of the best
educational methods, he is the typification of the "scholar in
medicine"; and, the apostle of industry and thrift, he is, in
both a scientific and pecuniary sense, an illustration of conspicu-
ous success in his profession. That he should have been re-
moved is deplorable ; but that the committee should have per-
mitted itself to be thus imposed upon is still more so. If the
forty-six gentlemen comprising that committee are so ignorant
of the true status of the great men of our profession, they are
simply unfit for the duties devolving upon them.
Cincinnati, as your readers all know, has an extensive repu-
tation as an art center ; but the fact that several members of
the medical profession have become quite accomplished artists,
while not at all surprising, is yet not so generally known. One
of our most accomplished dilettanti is Dr. Daniel S. Youngr
whose office and studio are crowded with treasures and curios,
that are the products of his artistic tastes. His efforts cover
almost every department of art; oil and crayon pictures abound,
while etchings are not rare; and wood-carving and sculpture in
plaster are familiar pastimes. One of his most successful efforts
— a bas-relief in plaster of the late Dr. George C. Blackman —
adorns the walls of the library of the Cincinnati Hospital,
while the rare museums of the Cuvier Club and of the Cincin-
nati Natural History Society are largely indebted to his skill
as a taxidermist for many of their most interesting and valuable
specimens. It may be proper to add that Dr. Young is a hard
worker in his profession, and finds time for his art labors amid
the exactions arising from his extensive private practice, from
his duties as staff surgeon to the Cincinnati Hospital, and from
his work as a clinical teacher of surgery. One of the most
promising of our younger men, whether viewed as physician or
artist, is Dr. W. Kincheloe Baker. He has achieved his celeb-
rity as an artist chiefly through the rare superiority of his
-etchings. His work, particularly in this department, is far
above the order of dilettanteism. Among his more recent pro-
ductions is an etching of the late Dr. Samuel D. Gross — cer-
tainly one of the most striking likenesses and effective pictures,
it has ever been my pleasure to behold. Another of Dr. Ba-
ker's etchings is of the late Dr. William Judkins, pere ; that it,
too, is a faithful picture is assured by the indorsement of the
present owner of the plate, Dr. William Judkins, fils, and by
those who were the compeers and colleagues of the distinguished
pioneer. Dr. Reamy, an elegant subject for a picture, is an-
other well-satisfied patron of Dr. Baker's art. Another of our
physicians, Dr. William A. Rothacker, the editor of " Henke's
Atlas," although not engaged in art production, is, however,
professor of anatomy at the art school. In addition to these,
the profession of Cincinnati affords a large number of art ama-
teurs ; but while writing of the amateurs within the profession
it may not be amiss to mention one of the most promising, who
is connected with it only by marriage — Mrs. J. H. Hazard, wife
of the professor of physiology at the Cincinnati College of
Medicine and Surgery. She has especially distinguished herself
by executing in oil the elegant drawings with which her hus-
band illustrates his lectures. It may be added that as an anato-
mist Mrs. Hazard has but few superiors, even in the profession.
Sept. 5, 1885.
LEADING ARTICLES.
267
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by
D. Appleton & Co.
Edited by
Fbank P. Poster, M. D.
NEW YORK, SATURDAY, SEPTEMBER 5, 1885.
THE HOBOKEN POISONING CASE.
The distressing incident that happened in Hoboken a few
days ago, whereby two young ladies lost their lives in conse-
quence of an apothecary's error, should at least serve to inten-
sify the vigilance with which pharmacists undoubtedly try to
guard against mistakes of this nature. There is, unfortunately,
nothing so rare in the occurrence, considered simply as an oc-
currence, as to make it specially monitory, but the exceptional
character of the gentleman whose hard fate it has been to com-
mit the error in this instance lends an unusual impressiveness
to the calamity. The public is quite generally impressed with
the idea that mistakes in the delivery of drugs to purchasers, or
in the compounding of medicines ordered by prescription, neces-
sarily imply either gross ignorance or inconceivable negligence,
each of which shortcomings, brought into play under such cir-
cumstances, is held to amount to criminality. In conformity to
this idea, the law not only holds persons whose mistakes of this
sort are productive of fatal results as fit subjects for punish-
ment, but aims to throw unusual safeguards about the practice
of pharmacy by requiring of persons who seek to follow that
pursuit ample evidence of their fitness for it.
In so far as the last-mentioned aim of the law is concerned,
its wisdom is unquestionable, but its adequacy to the purpose is
seen to be very imperfect when we reflect that, in the instance
which calls forth these remarks, so commonplace an error as
that of dispensing morphine instead of quinine was committed
by a gentleman who for years had stood among the foremost in
his profession. Although his place of business was in Hoboken,
where the ordinary working of the laws of trade would have
brought him only a patronage limited to the people of his im-
mediate neighborhood, he had become widely known to physi-
cians for his skill and carefulness as a pharmacist, as well as for
the trustworthy character of certain medicinal preparations and
surgical appliances that were his own special productions. Mr.
Am Ende has long occupied a most honorable position in the
estimation of the medical profession. Certainly it was no lack
of capability that led him into his fatal error. It is said that
his mistake is only to be accounted for by the fact that persons
who happened to be in his shop at the time persisted in talking
to him when he was engaged in putting up the prescription. It
is not at all unlikely that this is the true explanation, and, con-
sidering the aggravating persistency with which men engaged
in delicate and responsible work are distracted and worried by
chance visitors, the wonder is that accidents involving grave
consequences do not happen oftener.
Perhaps it would hardly do for the law to relax its hold
upon persons who make fatal mistakes in the practice of phar-
macy, but leniency, both on the part of the courts and on the
part of the community, is certainly called for in cases where, as
in the present instance, the lapse seems to be of a sort that no
man could be sure of being able to guard against with anything
like certainty. It is said that the father of the young ladies
who lost their lives has sent a message of sympathy to Mr. Am
Ende, and has even sent prescriptions to his shop since the fatal
occurrence. We trust that this is true, for it would go far to
allay a sense of grief that must be well-nigh unendurable. At
all events, we are glad to believe that it is with no approach to
vindictiveness that Mr. Am Ende is thought of by the better-
portion of the community.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending September 1, 1885 :
Week ending Aug. 25.
Week ending Sept. 1.
DISEASES.
Cases.
Deaths.
Cases.
Deaths.
1
0
0
1
29
10
34
3
14
4
13
2
Cerebro-spinal meningitis. . . .
3
1
2
1
12
6
9
1
31
17
21
11
The Health of the State of New York.— By the " Month-
ly Bulletin of the New York State Board of Health " for July
we learn that the total reported mortality for the month was
9,318, the percentage among infants being 54-4. The propor-
tion of deaths from zymotic diseases was 401 -37 in each thou-
sand, and that of deaths from diarrhoeal diseases 320.
The International Medical Congress.— We copy the fol-
lowing from the "Louisville Medical News":
" Charleston Physicians and the New Organization. — The
undersigned, for reasons connected with the changed circum-
stances in the organization of the proposed International Con-
gress, since their appointment in the several sections, hereby
respectfully withdraw their names.
"Middleton Michel,
"F. Peybe Poroher,
" Francis L. Parker.
" Chicago Physicians and the New Organization of the Con-
gress.— Believing that the American Medical Association, at its
late meeting in New Orleans, took such action with reference
to its committee, appointed one year before, to unite, arrange
for, and organize the Ninth International Medical Congress, as
to nullify in part the work performed by said committee, there-
by jeopardizing the success of the proposed Congress and put-
ting the medical profession of this country in a false and un-
favorable light, the undersigned disapprove of this action of the
association, and decline to serve in the positions to which they
have been appointed in the Congress as at present organized.
" A. Reeves Jackson, N. Senn,
" Henry M. Lyman, Charles T. Parker.
" James Nevins Hyde,
" Other Resignations from the New Organization. — We are
informed that Dr. Edwin M. Snow, of Providence, has declined
the vice-presidency of the Section of Collective Investigation,
Nomenclature, and Vital Statistics, and that Dr. D. Bryson
Delavan, of New York, has declined the secretaryship of the
Section of Laryngology.
268
MINOR PARAGRAPHS.
[N. Y. Med. Jodb.,
" Dr. Thomas F. Wood, of Wilmington, N. C, has declined
to serve on the Council of the Section of Practical and Ex-
perimental Therapeutics ; likewise Drs. J. Rufus Tryon, U. S. N.,
and Alfred A. Woodhull, U. S. A., on the Council of the Sec-
tion of Military and Naval Surgery and Medicine, and Dr. Chris-
tian Fenger on the Council of the Section of Pathology."
Editorially, the same journal says:
" The American Medical Association's new Committee on
Pules and Preliminary Organization of the International Medi-
cal Congress of 1887 will meet by special call for the transaction
of important business in New York on the 3d of September.
" The importance of this meeting can not be overstated,
since it involves nothing less than the fate of the Congress and
the good name of American medicine abroad. For, in spite of
the large boasting of the new committee's supporters, that the
recent numerous withdrawals of eminent men from among its
appointees would not make against the successful meeting and
working of the Congress, it is certain that the wise and far-
seeing of the committee must own a serious loss of strength,
and perceive that, as it is now proposed to be organized, the
Congress will be a sorry failure, if indeed it be not kept from
coming to this country.
" It is time to call a halt to controversy. Let the attending
physicians take further counsel and ascertain if there be any
sign of life in this object of deep professional solicitude. If so
much as a spark remain, let it be duly fanned and fed ; but if,
as seems more probable, decomposition is already far advanced,
the sooner the remains are given decent burial and the premises
disinfected the better for those whose blundering treatment
killed their precious charge."
A Proposed International Dental Congress.— On account
of the dropping of the Section in Oral and Dental Surgery from
the organization of the Ninth International Medical Congress,
as at present laid out, the project has been broached among our
dentists of holding an International Dental Congress in Wash-
ington at the same time with the meeting of the Medical Con-
gress. The "Independent Practitioner" deprecates the scheme.
It says :
" We can not, without serious loss of dignity, sue to the
present General Committee of the Congress for reinstatement as
a section, after being once dropped by them under humiliating
circumstances. Nor should we wish such reinstatement, in the
face of a probable failure.
"Should the section not be re-established, it would, to
our mind, be a very questionable act to call an International
Dental Congress to meet at the same time, for the following
reasons: We probably could not make of it a success. We"
should be in a very undignified position, as a kind of hanger-on
to a Congress from which we had been rudely repulsed. We
could have no connection with the Congress, any more than
would a meeting of photographers, or commercial drummers, or
spindle-shanked bicyclists. We should not even be a part of
the tail to the medical kite, for we should have no connection
with it. We could not secure foreign attendance, for the den-
tists of Europe would value their dignity too much to attend
such a meeting, even were we so forgetful of our own as to in-
vite them.
"The only thing for dentists to do is to pursue the even
tenor of their way, doing what they can for the proper recon-
struction of the General Committee of the Congress. If this be
secured, and the meeting promises to be a success, we shall
doubtless be invited to take a part in it. If not, we are lucky
to be out of it, for we should present but a sorry spectacle
should we labor either for our own re-establishment in the Con-
gress under the present regime, or for the organization of a
separate International Dental Congress, and, when we were
fully committed, find to our chagrin that an event, which now
seems extremely probable, had occurred, and the acceptance of
the invitation to meet in America had been withdrawn and
the meeting called for Berlin."
The American Dermatological Association elected officers
as follows at its recent annual meeting: Dr. Edward Wiggles-
worth, of Boston, president; Dr. I. E. Atkinson, of Baltimore,
and Dr. A. R. Robinson, of New York, vice-presidents ; Dr. G.
II. Tilden, of Boston, secretary; and Dr. II. W. Stelwagon, of
Philadelphia, treasurer.
The meeting held in Greenwich last week was of a charac-
ter to show the continued vitality of the association, but yet
the discussions and the papers read were such as to appeal
more directly and forcibly to the general practitioner than is
apt to be the case with the proceedings of special societies. The
attendance, too, was fairly representative of the different quar-
ters of the country, and included nearly all of our better-known
dermatologists. Dermatology, as our readers are well aware,
is one of the departments of medicine in which America has
been able to make a creditable showing, and hence the career
of this association is of special interest to the profession.
The American Rhinological Association will hold its third
annual meeting at Lexington, Ky., on Tuesday, October 6th.
Papers and discussions will be devoted exclusively to the diseases
of the nasal passages and their consequences. The following is
the list of officers for 1885 :
President, Dr. P. W. Logan, Knoxville, Tenn. ; First Vice-
President, Dr. A. De Vilbiss, Toledo, Ohio; Second Vice-Presi-
dent, Dr. J. A. Stucky, Lexington, Ky. ; Recording Secretary,
Dr. C. A. S. Sims, St. Joseph, Mo. ; Librarian, Dr. R. N. Gor-
don, Springfield, 111. ; Council, Dr. J. G. Carpenter, Stanford,
Ky. ; Dr. H. Jerard, East Lyune, Mo. ; Dr. H. Christopher, St.
Joseph, Mo. ; and Dr. E. F. Henderson, Los Angeles, Cal.
Full information may be obtained from any of the foregoing
officers of the association.
The Indiana State Medical Society. — At the last annual
meeting of the society an unpleasant occurrence took place, as
some of our readers may remember, being no less than the
charge, brought against a gentleman who read an account of a
case in which he trephined the vertebral column, that an opera-
tion reported as trephining really consisted only in " scraping
of the spinous processes." Dr. C. B. Stemen, the author of the
paper, who is also the editor of the "Fort Wayne Journal of
the Medical Sciences," now gives in that journal evidence which
certainly seems to show conclusively that the accusation brought
against him at the meeting was unjust.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from August 22, 1885, to August 29, 1885:
Cronkhite, H. M., Captain and Assistant Surgeon. Relieved
from duty at Fort Reno, Indian Territory, and assigned to
duty as post surgeon, Fort Hays, Kansas. S. O. 129, De-
partment of the Missouri, August 26, 1885.
Powell,, J. L., Captain and Assistant Surgeon. Relieved from
temporary duty at Fort Leavenworth, Kansas, and assigned
to duty as post surgeon at Fort Lyon, Colorado. S. 0. 128,
Department of the Missouri, August 25, 1885.
Ebert, R. G., Captain and Assistant Surgeon. Assigned to
temporary duty with United States troops at Riverside Park,
New York. S. O. 179, Department of the East, August 24,
1885.
Kane, John J., Captain and Assistant Surgeon. Granted leave
of absence for one month, to take effect when his services
I can be spared. S. 0- 195, A. G. 0., August 26, 1885.
Sept. 5, 1885.1
PROCEEDINGS OF SOCIETIES.
269
Stephenson, William, First Lieutenant and Assistant Surgeon.
Granted leave of absence for one month, to take effect Sep-
tember 1, 1885 (Fort Niobrara, Nebraska). S. O. 79, De-
partment of the Platte, August 20, 1885.
MoCawvW. D., First Lieutenant and Assistant Surgeon. As-
signed to temporary duty at the camp of the troops near
Kiowa, Kansas. S. 0. 128, Department of the Missouri,
August 25, 1885.
Naval Intelligence. — Official List of Changes in the Medi-
cal Corps of the United States Navy during the weeh ending
August 29, 1885.
Jones, William H., Surgeon. Detached from the Wachusett,
and waiting orders.
Society Meetings for the Coming Week :
Monday, September 7th: New York Academy of Sciences
(Section in Biology); Medico-Ohirurgical Society of German
Physicians ; Morrisania Medical Society (private) ; Brooklyn
Anatomical and Surgical Society (private); Utica, N. Y.,
Medical Library Association ; St. Albans, Vt., Medical Asso-
ciation ; Providence, R. I., Medical Association ; Hartford,
Conn., City Medical Association ; Chicago Medical Society.
Tuesday, September 8th : New York Medical Union (private) ;
Medical Societies of the Counties of Rensselaer and Chemung
(Elmira), N. Y. ; Newark (private) and Trenton (private),
N. J., Medical Associations.
Wednesday, September 9th: New York Pathological Society;
American Microscopical Society of the City of New York;
Medico-Legal Society ; Medical Societies of the Counties of
Cayuga and Montgomery, N. Y. ; Philadelphia County Medi-
cal Society ; Worcester District, Mass., Medical Society
(Worcester).
Thursday, September 10th : Harlem Medical Association of the
City of New York; Society of Medical Jurisprudence and
State Medicine ; Brooklyn Pathological Society ; South Bos-
ton, Mass., Medical Club (private) ; Pathological Society of
Philadelphia.
Friday, September 11th: Yorkville Medical Association (pri-
vate); Medical Society of the Town of Saugerties, N. Y.
AMERICAN DERMATOLOGICAL ASSOCIATION.
Ninth Annual Meeting, held at Greenwich, Conn., Wednesday,
Thursday, and Friday, August 26, 27, and 28, 1885.
The President, Dr. W. A. Hardaway, of St. Louis, in the
Chair.
Wednesday's Proceedings.
A Case of Tuberculo-ulcerative Syphilide of Hereditary
Origin was the title of the first paper, by Dr. J. E. Graham, of
Toronto. The patient was a girl twenty years of age. The
skin of the forearm presented elevations and depressions, and
in places it was covered with thin scales. For three or four
inches above the elbow the arm was atrophied and covered
with cicatricial tissue. At the upper border of the cicatricial
tissue there was an ulcer three fourths of an inch wide, which
encircled the arm. Above this there was sound tissue. No
nodules were present. The left clavicle presented about its
middle a swelling and an ulceration of about the size of a silver
dollar. This was the result of a blow. There was no copper-
colored appearance. Investigation of the family history showed
that the mother was apparently healthy. The father died from
pneumonia when the patient was eighteen months old. It was
subsequently learned that he had also had syphilitic ulceration
of the throat. The treatment consisted in the local application
of a mild mercurial ointment and the internal use of bichloride
of mercury and iodide of potassium. The condition steadily
improved, and in the course of six or eight weeks the ulcera-
tion had healed. The patient at that time passed from ob-
servation.
The speaker referred to the difficulties of diagnosis in this
case, as there was a complete absence of specific history, the
facts in regard to the father not being learned for some time
after the case had been under treatment. There was no history
of any previous evidence of hereditary syphilis, but, taking all
the facts into consideration, there could be no doubt as to the
correctness of the diagnosis. Photographs showing the condi-
tion were exhibited.
Dr. R. W. Taylor, of New York, said it was now generally
conceded that syphilis could be communicated to the child with-
out infection of the mother, and he believed that he had been
the first one in America to call attention to this fact. He had
seen this a number of times. The author had stated that he
could obtain no history of early manifestations of hereditary
syphilis. This was not uncommon, but he believed that there
was usually some indication of specific taint, although it might
be so slight as not to excite notice.
Dr. C. Heitzman, of New York, said that every one had
seen cases similar to the one reported. He had seen cases in
which he was unable to determine the nature of the affection at
first sight. The diagnosis lay between syphilis and scrofula.
Dr. F. B. Greenough, of Boston, said that within the past
two months he had seen a woman who had lost three children
in succession from hereditary syphilis, yet she was strong and
apparently perfectly healthy, and had never shown any signs of
syphilis. This woman had been under observation for six or
seven years.
Dr. L. A. Duhring, of Philadelphia, said there were certain
cases in which it was almost impossible to express a positive
diagnosis at first. The result of treatment in causing a rapid
cure in the case described would certainly incline him to the
opinion that this was a case of syphilitic disease.
Dr. J. N. Hyde, of Chicago, had seen cases which had con-
vinced him that, while it was not the rule, still occasionally
syphilitic children were born without, so far as observation
could be made, any evidence of syphilis being detected in the
mother. So far as the general health was concerned, he could
not say that he had seen vigorous, healthy women the mothers
of syphilitic children. The women were usually pallid and
weak, although there might be no symptoms which could be
ascribed to syphilis. He saw inherited syphilis in infants con-
stantly, but he had never seen it manifesting itself for the first
time in advanced years, or, if he had, he had failed to make the
proper diagnosis. The more he saw of syphilis, the more was
he satisfied that in its origin heredity did not amount to very-
much. The accidental cases of syphilis were very common. He
had seen the initial lesion of syphilis on the head of a penis
where it was unquestionably due to inoculation from the finger
of the surgeon in catheterization. He had no doubt that the
case described was one of syphilitic trouble, and, as Dr. Duhr-
ing had said, the result of treatment unquestionably pointed in
that direction. There were no cases which yielded so readily
as old cases of untreated syphilis. As to pronouncing it a case
of hereditary syphilis, his experience would not permit him to
do so.
The President thought that it was unwise to base our diag-
nosis on the results of internal treatment. If a patient got well
270
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jock.,
under anti-syphilitic treatment, it did not prove that the affec-
tion was specific. Local treatment was often all that was ne-
cessary.
Dr. Taylor entirely disagreed with Dr. Hyde as to the con-
dition of the mothers of syphilitic children. He had observed
them to be in robust health.
Clinical Notes on Psoriasis. — Dr. Greenottgh read a paper
founded on the records of 394 cases of psoriasis. This num-
ber occurred in about 15,000 cases of skin diseases examined,
and represented about two and one half per cent. Many of the
patients were first attacked between th« ages of ten and forty
years. In 97 cases the speaker had been able to get reliable
evidence in regard to the family history. In 31 cases psoriasis
had existed in a near relative, but in 66 cases the patients felt
sure that the disease had existed in no other member of the
family.
Well-marked cases were readily diagnosticated, but in some
cases there was considerable difficulty in making the diagnosis.
The disease was most frequently confounded with some form
of eruption resulting from constitutional syphilis. When psori-
asis affected the scalp its appearance was often similar to that
of secondary syphilis. In psoriasis, however, the patch con-
sisted simply of epithelial cells, and there was no hyperaemia
connected with it. In the syphilitic eruption the crust con-
tained other elements than epithelial cells, and, on removing
the crust, spots of moisture would be detected. A characteris-
tic symptom of psoriasis of the scalp was a band of hyperaemia,
about three fourths of an inch wide, extending around the fore-
head, contiguous to the hair. This was a point of value in the
diagnosis between eczema capitis and psoriasis. In the former
affection this band was wanting. In eczema, also, evidences of
dried serum or pus would be found. Psoriasis was not accom-
panied with enlargement of the posterior cervical glands like
eczema. The diagnosis from favus was made by the age of the
patient, the evidences of destruction of the hair follicles in
favus, and the microscopical examination. On the general in-
tegument, syphilides were most apt to resemble psoriasis. The
regions on which the eruption appear was important. The
syphilides were apt to affect the flexor surfaces, while psoriasis
affected more commonly the extensor aspects. Psoriasis began
as a minute point of hyperaamia, which might last for several
days. In the macular syphilide a crop of macules appeared
within twenty-four or forty-eight hours. When the eruption
faded there was in syphilis a decided pigmentary change. In
some cases of psoriasis there was severe itching leading to
scratching of the skin, and, as a result, scabs and crusts made
their appearance, but here the cause of the condition was read-
ily recognized. The amount of pruritus complained of in psori-
asis varied, but it was rarely a prominent symptom, although
in exceptional cases it is very severe. In regard to treatment
there was no specific. What would benefit one patient might
make another worse. In his experience, tarry preparations,
especially the oil of cade, had been most efficacious. Great
comfort might be afforded by the use of emollients. Cod-liver
oil was one of the best applications. Cod-liver oil and oil of
cade (equal parts) was a common prescription. Chrysarobin
was a powerful remedy, but had the disadvantage of destroying
the clothing. On the face and scalp it was apt to produce der-
matitis. Eveu after apparent recovery there was great danger
of relapse.
Dr. Duhrino said that the reader had not alluded to the
difficulty sometimes experienced in diagnosticating seborrhoea
capitis from psoriasis. He had found considerable trouble in
the diagnosis, particularly in young girls. In these cases the
eruption was confined to the scalp.
Dr. A. R. Robinsox, of New York, said that in the diagnosis
of favus and psoriasis there was usually no difficulty. He did
not agree with the author in regard to one of his points of diag-
nosis. In the early stage we should not find "moisture when the
crust was removed. There was a shiny appearance. It was
only in advanced stages that ulceration was present. Jle con-
sidered it primarily an affection of the rete mucosum. While it
was true that psoriasis often disappeared without producing
pigmentation, there might be discoloration found on the lower
extremities, particularly where there was a varicose condition
of the veins.
Dr. J. C. White, of Boston, agreed with the previous speak-
ers in regard to the difficulty of diagnosticating between psori-
asis of the scalp and seborrhoea. In some cases the diagnosis
could not be made for months. In all parts of the body pig-
mentation might follow psoriasis, but never over large areas.
Dr. R. B. Morison, of Baltimore, saw a great many cases
of psoriasis, but could only recall one or two cases of psoriasis
in the negro. In such cases there was a loss of pigment.
Dr. G. H. Fox, of New York, thought too much stress was
laid on the general rule that psoriasis occurred most frequently
on the extensor surfaces, the knees and the elbows. It was a
notable fact that in general psoriasis the vicinity of the knee
and elbow escaped. Many cases of psoriasis occurred in weakly
subjects, while, on the other hand, many cases of eczema ap-
peared in robust persons. In every individual case, the better
the patient's health the less likely was he to suffer from a re-
currence of the affection. He had been very successful in the
treatment of proriasis, and in its management he adopted the
teaching of the late Tilbury Fox, who laid stress on the point
that in psoriasis, as in other inflammatory affections of the skin
and also in lupus, the first thing to do was to lessen the conges-
tion of the skin. The speaker did this by restricting the diet,
and ordering fruits and vegetables. Tea, coffee, tobacco, and
stimulants of all kinds were to be cut off. By so doing, more
would be accomplished than was obtained by using arsenic and
local applications at the start. In regard to local remedies, he
never used tar in the treatment of psoriasis. With the applica-
tion of chrysarobin made at the proper time, there was no ne-
cessity for the use of tar. He had seen many cases in which
this drug did no good, but this was because the application was
made when the patches ©f psoriasis were in a congested condi-
tion. If the acute congestion was lessened, chrysarobin will
produce beneficial results.
Dr. C. Heitzman, of New York, thought that one of the
most important points after making the diagnosis was to decide
as to the acuteness or chronicity of the affection. If it was
acute, local applications were to be avoided. If the case was
chronic, chrysarobin might be used with advantage at least
temporarily. It was not a cure. He agreed writh Dr. Fox that
restriction of the diet was important for the purpose of lessen-
ing the congestion. Tar could not be dispensed with. Chrysa-
robin remedied the disease for a time, but in a few months it
returned. There was nothing like tar to prevent the recur-
rence. No mention had been made of pyrogallic acid, which
did good in some cases. There were, however, some cases
which could not be treated successfully with any remedies; the
disease would steadily grow worse.
The President believed that in psoriasis we had a disease
situated in the skin itself. It is frequently hereditary. The
same sort of skin might be transmitted, just as a certain color
of the hair or of the eye might be transmitted, and then any ex-
citing cause might develop the psoriasis. He had seen psoriasis
follow eczema. It was not unlikely that in seborrhcea of the
scalp there might be the development of psoriasis. Internal
causes might produce it. He had seen the excessive use of oat-
meal produce typical psoriasis. In the treatment of psoriasis
Sept. 5, 1885.]
PROCEEDINGS OF SOCIETIES.
271
it was important to regulate the diet. He cut off meats, and
aided digestion in all possible ways. As a local application,
chrysarobin with salicylic acid was very useful in chronic cases.
Arsenic was useful on account of its action on the skin. This
treatment might be followed by the application of sulphur oint-
ment. In psoriasis of the scalp 9ulphur was quite an efficient
remedy.
Dr. Greenough had not intended to cover the entire subject
of psoriasis in my paper. The omission of a consideration of
seborrhoea was an oversight. In regard to pigmentation he had
referred especially to those cases of psoriasis of the trunk which
were most apt to be confounded with syphilides.
Cases of Angioma Pigmentosum et Atrophicum.— Dr.
White reported two cases. The first patient was a young man,
seventeen years old, a Russian Pole. Freckles appeared on his
face before he was two years of age. These increased in num-
ber until the age of six. When the telangiectatic condition first
appeared was not noted. When seen, the patient was well de-
veloped and apparently in good health. He had, however,
grown slowly, and was now no larger than a boy of twelve.
The hair of the head was abundant and intensely black. The
eyes were also black. The forehead and lower portion of the
face were of a dark-brown color, and, on close inspection, small
spots of a darker color were seen. The whole trunk was as
dark as the skin of a dark Spaniard. The scrotum was very
black, and the penis and glans presented dark spots. The arms
and hands were thickly spattered. The legs were also affected.
On the right thigh there was one spot of dark color covered
with rather long hair. The mucous membrane of the mouth
and pharynx was free from melanosis. On the right side of the
face, occupying one half the surface, was a sharply defined area
of white cicatricial-looking skin. Similar areas were seen on
the other cheek, on the forehead, and about the mouth. A few
white spots were seen on other portions of the body. The sen-
sibility of the affected areas was decidedly lessened. Over
parts of the face there were bright-red spots, varying in size
from that of a pin's head to that of a pea. They were most
noticeable in the atrophied portions. Within the lids there were
two angiomatous new growths. Several vascular twigs were
also seen on the face. A few red points were found on the
general surface.
The second case was that of a brother of the first patient,
aged three years, born in New York. When he was eighteen
months old, little colored freckles were noticed on the face.
Since then the condition had been developing. His hair was
dark brown and his eyes were black. The face was covered
with numerous dark-brown freckles. The spots were so close
together that at a little distance the skin had a uniform color.
In some places the spots were slightly elevated. The backs of
the hands were covered with dark-brown spots ; elsewhere the
skin was clear. There were no leucodermic spots and no angio-
matous conditions.
From a study of these cases, he concluded that in the begin-
ning the development of these spots could not be distinguished
from that of ordinary freckles. Gradually the spots multiplied
until they involved a considerable portion of the skin. It was
probable that several years might elapse without other mani-
festation of the disease. The telangiectatic condition was proba-
bly secondary. In the first case it was most developed in the
atrophic portion. It was probable that in this case there would
be hypertrophy of the epithelium and final transformation into
epithelioma. This had been the result in the thirty-three cases
which had been reported.
The Relations of Lupus Vulgaris; to Tuberculosis.— Dr.
Hyde read a paper in which the following clinical facts were
cited in support of the view that lupus vulgaris was not the
result, as had long been taught, of tuberculosis or other sys-
temic diathesis, but was the product of a local infection by
bacilli, entirely unassociated with any constitutional evidence
of diathesis or predisposition : 1. The unimpeachable cbai^acter
of the family record in by far the larger number of cases of
lupus vulgaris. 2. The fact that the disease was in its inception
a disorder of the period of childhood, when for the most part
the habits of the child were favorable to infection. 3. The
several sites of predilection were those most favorable to such
infection. 4. The failure of the disease to spread by inherit-
ance. 5. The remarkable tendency of lupus vulgaris to cutane-
ous limitation.
The Treatment of Lupus by Parasiticides.— Dr. White
reviewed briefly the evidence in favor of the parasitic nature of
the affection. All previous plans of treatment which had
proved most successful were those which would have the effect
of destroying any parasite which might be present. A number
of cases were then reported in which the local use of corrosive
sublimate, in the strength of two grains to the ounce of water
or unguent, had been used with beneficial results. The oint-
ment was especially recommended. It had been rarely neces-
sary to prolong the treatment over two months. As regarded
the permanency of the cure the author was unable to speak, as
the experiments had been continued for only eighteen months.
Dr. S. Sherwell, of Brooklyn, would express his profound
disbelief in the parasitic nature of the disease, and he did not
know that the theories of Koch had been entirely proved.
Dr. Hyde said that at the last meeting Dr. Taylor had sug-
gested the use of a solution of corrosive sublimate in tincture of
benzoin. He had used this in cases of lupus and in cases of
infecting chancre. It made an excellent application.
The Treatment of Port-wine Mark by Electrolysis.— The
President read a paper with this title. In the treatment of
this affection the object was to excite sufficient inflammation
to cause occlusion of the vessels. Electrolysis seemed to be the
most convenient way of doing this. At first the author had
used a bundle of needles, but he now employed only the single
needle. It was important to allow a period of some weeks to
elapse between the applications. The histories of three cases
were given in wrhich this method had been employed.
Dr. Wiggles worth, of Boston, had seen good results from
cutting the vessels in two places and using a preparation of
iron, thus closing up the dilated vessels.
Dr. Fox thought that better results could be obtained by
electrolysis than by other measures, but it did not remove the
trouble entirely. He had used the treatment with puncture
and carbolic acid with fair results. He had sometimes passed
the electrolytic needle deeply, endeavoring to strike the artery
of supply, and sometimes had produced a decided effect.
Dr. Le Grand N. Denslow, of Minneapolis, had recently
seen a case of port-wihe mark on the labia majora of an infant.
This had ulcerated when the child was brought to him. As a
temporary measure, he applied the liquor gutta-perchaj. In
two days, without other treatment, the whole mark sloughed
out, leaving nothing but a simple ulcer, which completely
healed in the course of three weeks.
The President thought that the advantage of electrolysis
was that it was manageable. A practical point might be re-
ferred to, and that was, if after the operation the part was fre-
quently mopped with hot water, the inflammatory disturbance
would be greatly lessened.
Remarks on a Moot Point in the Etiology of Psoriasis.
— Dr. Sherwell read a paper with this title. He had been
struck by the great diversity of opinion in regard to the general
health of those affected with psoriasis, and, in order to arrive at
something like a consensus of opinion on the subject, he had
272
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Joub.,
referred to the writings of most of the authorities in dermato-
logical matters. Brief extracts from various winters were then
given. The evidence thus obtained strengthened the author's
opinion that the patients with psoriasis were generally in good
health. He thought that the theory of Piffard, who believed
that the rheumic diathesis was a great exciting cause of psoriasis,
was the most rational theory that had been advanced.
(7b be concluded.)
NEW YORK SOCIETY OF GERMAN PHYSICIANS.
Meeting of June 22, 1883.
Dr. B. Sohaelau, and afterward Dr. I. Adleb, in the Chair.
Ulcerated Gumma of the Sternum.— Dr. Hermann G.
Klotz presented a man, sixty years old, whom he had treated at
the German Dispensary. Three weeks ago he hurt his chest
by striking against a hard object. Soon after he noticed a hard
swelling which developed at the seat of the injury and finally
ulcerated, but never gave him any pain. The nates and thighs
exhibited pigmented scars, but there were no swollen glands.
Dr. Klotz considered the swelling to be an ulcerated gumma.
Kelotomy combined with the Radical Operation for
Inguinal Hernia. — Dr. I. Adlek presented a man, twenty-
three years old, on whom he had performed this operation at
the German Hospital four weeks ago. The patient had been
afflicted with an irreducible hernia ever since he could remem-
ber, but had never worn a truss. When the doctor first saw
him his abdomen was tense and painful, and he suffered from
hiccough, nausea, and vomiting. His bowels had not moved for
four days in spite of some homoeopathic medicine prescribed
for him by an irregular practitioner. The hernia! protrusion
gave a dull percussion sound. Dr. Adler at once proceeded to
perform kelotomy. On opening the hernial sac, it was found to
contain omentum which was firmly adherent to the hernial sac
in many places, and a small, dark-red knuckle of intestine. The
whole inguinal canal was laid open, and the internal ring was
freely incised, whereupon the strangulated portion of intestine
slipped back into the abdominal cavity. The adherent portions
of the omentum were ligated and cut through with the ther-
mo-cautery. The operation was supplemented by the radical
procedure for hernia — viz., the stitching of the internal ring,
which was done with stout catgut. The dressing was changed
on the fourth day, and he was discharged at the end of two
weeks.
Haemorrhage following Abortion.— Dr. J. Boldt exhibited
an ovum of the fourth week of gestation. The haemorrhage
occasioned by the miscarriage lasted about two weeks and was
stopped only by scraping the uterine cavity.
Tetanus following Abortion.— Dr. Henry Wald reported
the case of a woman, thirty-six years old, who had a miscarriage
in consequence of excessive exertion, and in whom lockjaw set
in three days afterward. Treatment was of no avail, and she
died at the end of three days of suffering. At the time of death
her temperature was 106° F.
Dr. I. Adler remarked that he had once tried nerve-stretch-
ing in a case of tetanus caused by a gunshot wound of the
thumb, but without success.
Prolonged High Temperature.— Dr. A. Selbert reported
the case of a baby, four months old, which he had treated for
gastritis, and which for eighteen consecutive days almost unin-
terruptedly had a temperature of over 106°. The child recov-
ered.
Tetany. — Dr. J. Rudisoh related the case of a child, four
years old, who at the time of the meeting was convalescing from
an attack of tetany supposed to have been caused by taking
cold while sleeping near an open window. The attack began
with a severe headache, which was aggravated every time th»
little patient took nourishment. On the fourth day mastication
and deglutition became difficult, and the usual symptoms of
tetany were ushered in. Warm baths were at first employed,
but they appeared to aggravate the convulsions ; neither did
salicylic acid produce any amelioration. The patient was then
put on chloral hydrate and bromide of potassium, and the occa-
sional use of amyl nitrite.
Operation for Empyema.— Dr. A. Oaille reported a suc-
cessful operation of this kind which he had performed in a
child fourteen months old. He employed Labarraque's solution
for washing out the pleural cavity. Six weeks after the opera-
tion the little one had gained three pounds.
Meeting of September 28, 1883.
Dr. B. Sohaelau in the Chair.
Dr. J. Boldt introduced a man, thirty-two years old, on
whom Prof. Langenbeck, of Berlin, had performed exsection of
the left elbow joint in the year 1876, resulting in a perfectly
useful limb.
Perforation of the Lower Canaliculus due to Syphilis.
— Dr. A. Schapbinger presented a married woman, aged twenty-
six years, with a perforation of the left lower lachrymal cana-
liculus, the result of ulceration of a tubercular syphilide which
had occupied the region of the inner canthus. The patient
having been put through a course of iodide of potassium, the
syphilitic nodule itself had disappeared at the time she was
shown to the society. The slit-shaped perforation involved the
inner or nasal half of the lower canaliculus, transforming it
into a furrow, while the outer or temporal half, including the
lower punctum lacrymale, was normal. Through the slit-shaped
opening No. 6 of Bowman's probes could be introduced into the
lachrymal duct. There were also several small perforations in
the soft palate. Dr. Schapringer had not been able to find a
single case of perforation of a lachrymal canaliculus caused by
syphilis recorded in literature.
Gonorrhoeal Tenosynovitis. — Dr. A. G. Gebsteb reported
the case of a young man who, during the course of the second
week of his first gonorrhoea, was attacked by inflammation, fol-
lowed by suppuration, of the tendon sheaths of the flexors of
the middle finger and of the tibialis anticus. The abscesses
formed were incised and washed out with a strong solution of
corrosive sublimate. The wound healed in four weeks. Dr.
Gerster considered this to be a case of metastatic gonorrhoeal
synovitis.
Dr. H. Knapp said, in answer to a question from the chair-
man, that the existence of a metastatic form of iritis due to
gonorrhoea was established beyond any doubt, though it did not
occur frequently. Whenever a patient suffering from iritis
complained to him about pains in the knee, he always diagnos-
ticated the presence of gonorrhoea, and had as yet never made a
mistake.
Dr. I. P. Oberndorfer expressed doubts as to the existence
of a causal relationship between gonorrhoea and rheumatism,
and believed that the combination of the two diseases was
purely accidental.
Dr. Gerster had seen about thirty cases of articular rheu-
matism following recent gonorrhoea or mechanical irritation of
the inflamed mucous membrane of the urethra, and was con-
vinced that the latter was the cause of the former. He had had
repeated experience of the fact that the passing of a sound was
followed either by inflammation of a joint, or by an exacerba-
tion of an existing inflammation. These inflammations, as a
rule, were very stubborn to treatment. In three cases in which
Sept, 5, 1865.]
PROCEEDINGS
OF SOCIETIES.
273
he had occasion to aspirate lie found that the joints contained
serum mixed with a small quantity of pus. A number of cases
of gonorrhoeal rheumatism turned into the tuberculous or fun-
goid form of arthritis. Dr. Gerster once had to perform partial
exsection of a knee joint affected in this way. Ankylosis was
often the result of this form of joint disease. In the treatment
of gonorrhoeal rheumatism, not only the original trouble should
receive attention, but also the joints affected should have the
benefit of special surgical care.
Dr. J. Rudisoh remarked that the term "gonorrhoeal rheu-
matism " ought to be discarded, because it was apt to be mis-
leading in regard to therapeutics. Salicylic acid was never of
any benefit in this disease. He had observed that the continued
treatment of the urethral affection by injections always aggra-
vated the joint trouble. He recommended the administration
of iodide of potassium, to put the joint in splints, and not to
meddle with the urethra at all.
Dr. Obeendorfek said that, if it was true that the suppression
of the gonorrhoeal secretion by local applications was apt to start
or to aggravate joint inflammation, this fact was an argument
against the view that the joint disease was due to gonorrhoeal
infection, because a cessation of the gonorrhoeal flux could only
be brought about by killing the micrococcus which caused it,
and, if this was done, then the micrococcus, being dead, could
not possibly cause any metastasis. He also thought that, if the
arthritis was caused by the Diplococcus gonorrhcece, the effusion
into the joint would invariably be purulent.
Dr. Gerster reminded Dr. Oberndorfer that, whenever a
general infection of the system took place from a pus-secreting
focus situated anywhere in the body, one of the first symptoms
was the cessation of the secretion of pus at the initial lesion.
The usual method of making injections into the urethra, as
practiced by the patients themselves — i. e., by pressing the walls
of the meatus tightly against the nozzle of the syringe — was apt
to cause infection of the system by forcing gonorrhoeal material
into open lymph-channels in places where the mucous surface
was denuded of its epithelial lining. He preferred to make the
applications to the urethra himself wherever this was practi-
cable. The fluid which he preferred was a solution of corrosive
sublimate of 1 part to 5,000 or more, with which he irrigated
the urethra by means of a fountain-syringe and a soft catheter.
Dr. Rudisoh inquired whether the treatment of the urethral
mucous membrane had any influence upon the progress of gon-
orrhoeal iritis, if such a complication existed.
Dr. Knapp answered that in such cases he never interfered
with the urethra at all, and that the discharge from the urethra
always subsided without any local treatment. He thought that
the good effect of antiseptics could be accounted for by their
astringent property, in consequence of which they diminished
the amount of transudation, and thus deprived the micro-organ-
isms of the soil on which they fed.
Gonorrhoeal Ophthalmia.— Dr. Knapp also mentioned that
he had lately met with an unusual number of cases of this affec-
tion. In regard to treatment, he did not use nitrate of silver in
any form in the beginning, but restricted himself to measures of
cleanliness and the application of cold.
Meeting of October 26, 1883.
Dr. A. Jaoobi in the Chair.
Sarcoma of the Kidney.— Dr. Aug. Seibert exhibited both
kidneys of a girl ten months old, the right one of which was
the seat of a medullary carcinoma. He intended to publish the
case in detail at some future date.
Dr. Alfred Meyer remarked that sarcoma of the kidney
occurred more frequently than carcinoma in children.
Dr. Seibert replied that in the foregoing case he and Dr.
A. Seessel had become convinced, by means of microscopic ex-
amination, that the new growth was a carcinoma.
Dr. I. Adler contradicted the statement of Dr. Meyer with
reference to the frequency of occurrence of both classes of new
growths in the kidneys of children.
The Chairman remarked that more attention had been given
to tumors of the kidney within the past fifteen years. The
greater number of congenital as well as malignant new growths
which developed in infants and in children of one or two years of
age were found in the kidneys, and the majority of these tumors
were sarcomata. Haemorrhage hardly ever occurred with this
kind of tumor. He had observed six cases of sarcoma of the
kidney up to date, but had never seen one case of carcinoma.
Should carcinoma occur at all in children, its favorite seat
would be the kidney, but the greater number of new growths
of this organ were assuredly sarcomatous.
Dr. Adler was of the opinion that most of the so-called
primary sarcomata of the kidney did not originate in the kidney
substance proper, but began either in the supra-renal capsule
or in the pelvis of the kidney.
Sarcoma of the Left Side of the Face.— Dr. Adler pre-
sented a patient, forty-six years of age, upon whom he had
operated for the removal of a sarcoma of the left side of the
face five weeks previous. The tumor became noticeable about
one year ago, although the patient had experienced some diffi-
culty in mastication and swallowing for a considerable time
previous, evidently caused by the new growth. At the time of
the operation the region of the left parotid gland was the seat
of a tumor which was of the size of an apple. Above the zygoma
there was a smaller projection. The patient could not open his
mouth. Under the influence of chloroform a digital examina-
tion of the fauces was rendered possible. The left tonsil and
the uvula were pushed to the inner side, but were not united
with the tumor.
While extirpating the tumor it became apparent that the
new growth originated from the left lower maxilla, which
bone, together with the muscles attached to it, with the excep-
tion of the internal pterygoid, was removed. The parotid
gland was atrophied, but not involved in the tumor, and was,
therefore, not removed. The number of vessels ligated was
quite small ; among them was the internal maxillary artery. A
portion of the pterygoid process was removed. The wound
was dressed with iodoform, and healed without any signs of re-
action. A microscopic examination showed the new growth to
be a giant-celled round-celled sarcoma. At the time of this re-
port the patient was able to masticate.
Ossifying Giant-celled Sarcoma of the Foot.— Dr. Adler
showed the foot of a girl, seventeen years of age, which he had
amputated four months previous in the German Hospital. The
family history of the patient was phthisical.
The patient entered the hospital in January with a swelling
of one ankle joint, which was considered a fungous inflamma-
tion, and it was treated with ignipuncture. As the swelling of
the joint increased, Dr. Adler determined to perform a radical
operation. He made a longitudinal incision at first, as recom-
mended by Kocher, in order to explore for an intended exsec-
tion. A peculiar substance oozed forth, which at first sight
seemed to be fungous, and he determined to perform Symo's
amputation at once. A microscopic examination demonstrated
that this mass was an ossifying giant-celled sarcoma, which
projected from the anterior surface of the astragalus. The
scaphoid bone was not involved. The position of the new
growth corresponded with one of the previous ignipunctnres.
No trace of a fungous process was found on the joint surfaces
nor anywhere on the sheaths of the tendons.
274
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Joob.,
Dr. Adler was of the opinion that the new growth was pres-
ent at the time when the ignipuncturo was performed, and that
this operation caused a rapid proliferation of the same.
Dr. A. G. Gerster remembered a case which he observed
about one year ago, in which a sarcoma developed itself in the
bony cicatrix of a previous fracture of the external condyle of
the humerus.
Adenoid Vegetations. — Dr. Aug. Caille exhibited sev-
eral adenoid vegetations which he had removed by means of
Jarvis's snare from the naso-pharyngeal cavity of several pa-
tients.
Dr. Gersteb said that Jarvis's instrument had broken when
he had attempted to remove any dense swellings.
Dr. Adler said that he used the snare constructed by Zaufal,
of Prague, with the best success.
Extirpation of the Uterus and Ovaries. — Dr. Paul F.
Munde reported a case in which he had successfully extirpated
the uterus with the ovaries, at Mount Sinai Hospital. The
operation was performed on account of a carcinoma of the
cervix, the uterus being quite movable. The patient was placed
in Sims's position and the operation performed through the
vagina.
Dr. Gerster stated that Dr. Bopp had successfully removed
a uterus through the vagina. He had assisted at a similar opera-
tion, recently performed in Brooklyn, on accouDt of a total pro-
lapse of the uterus and vagina. This latter case progressed
favorably.
The Chairman remarked that the first operation for extirpa-
tion of the uterus ever performed was that done by Dr. Emil
Noeggerath in Hoboken about six years ago. The case termi-
nated fatally.
Tuberculosis of the Lung with Pneumothorax.— Dr. Al-
fred Meter exhibited the lung of a phthisical patient which,
becoming perforated a short time before death, caused pneumo-
thorax.
Dr. Meyer also showed the uterus and other organs of a
woman who had died of puerperal septicaemia.
Parenchymatous Inflammation and Fatty Degeneration
of the Kidneys. — Dr. H. J. Boldt reported the case of a wom-
an, twenty-nine years of age, who had been suffering with fron-
tal headache for several years. The headache was most intense
in the morning, and, as a rule, subsided in the afternoon. A
short time before death the woman was seized with periodical
rigors, which were not influenced by quinine. The urine at no
time contained albumin. The patient was seized with convul-
sions which passed into coma, and in this condition she died.
The autopsy did not corroborate the probable diagnosis of ab-
scess of the brain, there being only a hyperaemia and oedema of
the brain-substance.
Dr. Satterthwaite had examined the kidneys and found them
in the first stage of a parenchymatous inflammation or fatty de-
generation.
Meeting of November 30, 1888.
Dr. A. G. Caille in the Chair.
Empyema. — Dr. H. J. Boldt read the full clinical history,
and exhibited the lungs, of a man, twenty-two years of age,
who had apparently at first suffered from typhoid fever, and
afterward a pneumonia, to which he succumbed. The autopsy
revealed an empyema. During life bronchial breathing could be
heard distinctly over the empyema.
Dr. A. Jaoobi, who saw the case in consultation, stated that
he had heard the bronchial breathing, and thought that it was
caused by short adhesions between the costal and the visceral
laminse of the pleura. It was always necessary, he thought,
to make an exploratory puncture in doubtful cases.
Urine containing Casts but no Albumin.— Dr. Boldt
also spoke of certain cases of Bright's disease in which the urine
contained casts but no albumin.
Dr. CnARLES IIeitzman remarked that this peculiarity oc-
curred, in chronic Bright's disease, and Dr. Gustav Langmann
stated that it also occurred in acute cases.
Primary Sarcoma of the Kidney— Dr. Jaoobi exhibited a
primary sarcoma of the kidney of a boy, two years of age, who
had been admitted into Bellevue Hospital on August 8, 1883, on
account of distended abdomen and occasional vomiting. On
admission, the temperature was 101° F., and a swelling was
found on the right side of the abdomen. On percussion, tym-
panitic resonance was found in the space extending between
the liver and the swelling. The patient was put on a generous
diet, and alcohol and arsenic were administered.
September 20th. — The patient had improved, having good
appetite, but the swelling had increased in size. A diagnosis of
sarcoma of the kidney was made. The urine never contained
albumin or blood.
October 12th. — The swelling had become larger ; there was
marked dyspnoea; on the right posterior surface of the thorax
dullness was present, which corresponded to a watery sero-
sanguineous exudation, which was removed by aspiration.
The dullness over the tumor now coalesced with that of the
liver, and there was apparent fluctuation at a certain point.
This being punctured, some dark, bloody fluid was evacuated.
The tumor continued to grow rapidly, and finally the child died,
emaciated and exhausted. The autopsy revealed a large tumor
of the right kidney, which was inclosed in a dense fibrous cap-
sule, and to which the ascending colon and liver were adherent.
On section, the anterior portion of the tumor revealed a cyst
which contained about two hundred and fifty grammes of fluid.
In the middle of the swelling there was hsemorrhagic exudation.
The ureter was not degenerated, and extended up to the middle
of the tumor, where it joined a normal remnant of the pelvis.
The tumor itself was a soft, round-celled sarcoma.
Dr. Jacobi then spoke about the differential diagnosis of car-
cinoma and sarcoma of the kidney, and said that with a large
tumor and a history of comparatively fair health for a long
period of time the diagnosis of sarcoma was quite probable.
The course or clinical history of sarcoma was also of longer
duration than of carcinoma.
Osteo-sarcoma of the Right Jugular Bone— Dr. F. C.
Heppenheimer exhibited an osteo-sarcoma of the right jugular
bone which was not noticed until eleven months before death.
A resection was performed in Bellevue Hospital, but a new
tumor very soon appeared. Finally the tumor involved the
right side of the frontal bone, the entire inner surface of the
orbit, and perforated the right side of the ethmoid. From the
orbit the tumor extended to the right angle of the jaw, thence
under the chin to the middle portion of the digastric muscle,
where a round mass of the size of a small egg projected from
the main portion of the tumor. From here the tumor extended
backward to the anterior surface of the sterno-cleido-mastoid
muscle, and upward along this muscle to the level of the lobule
of the pinna. The tumor involved the entire region in front of
the ear, and, passing up obliquely, was bounded by the super-
ciliary ridge. The right eye was pushed forward and covered
by the lids. The patient, who was sixty-four years of age, died
of exhaustion.
Choroiditis Metastatica. — Dr. Heppenheimer showed the
eyes of a patient, thirty-three years of age, who had suffered
from a metastatic choroiditis. The patient died of a diphtheritic
endometritis.
Carcinoma of the Stomach. — Dr. Heppenheimer also ex-
hibited a connective-tissue scirrhus of the pyloric end of the
Sept. 5, 1885.]
PROCEEDINGS OF SOCIETIES.
275
stomach which would have been a favorable case for exsection.
The patient died of haemorrhage from the stomach.
A Floating Body in a Hydrocele.— Dr. Heppenheimer also
showed a floating body found in a hydrocele.
Carcinoma of the (Esophagus.— Dr. Alfred Meyer ex-
hibited the oesophagus of a woman, fifty-two years of age, which
was the seat of a carcinoma. In the previous July the patient
experienced difficulty in swallowing and pain in the epigastric
region. She vomited frequently and lost flesh and strength,
finally becoming so emaciated as to weigh ninety-two pounds
only. October 2d an incision was made, and an obstruction
was ascertained to be situated about twelve inches from the
incisors. An oesophageal bougie No. 5 was passed, which caused
an amelioration of the symptom and a marked increase in
weight. October 21st the patient began to vomit very frequently
and emaciated very much. This vomiting was followed by
coughing, the patient vomiting the contents of the stomach
mixed with pus. A short time before death she weighed fifty-
two pounds only. The autopsy showed a dilatation of that part
of the oesophagus situated above the stricture which measured
6-5 cm. in diameter, while the diameter of the oesophagus below
the stricture was 3-5 cm.
An ulcerative process, beginning at the new growth, per-
forated the right bronchus, thus establishing a communication
between this bronchus and the oesophagus.
In the right lung a suppurative bronchitis was found. In
the right axillary region a swollen gland was seen. Microscopic
examination showed an epithelioma. According to von Ziemssen,
this class of carcinoma of the oesophagus rarely occurred in
women.
Repeated Attacks of Scarlatina in a Child.— Dr. Gustat
Langmann reported a case of a boy, fourteen years of age, who
had had twenty-four attacks of scarlatina. About twelve years
and a half ago the patient had his first attack of scarlatina com-
plicated with diphtheria. This occurred in the year 1871, and
since that time he had had a regular attack of scarlatina every
spring and fall. The rash, angina, rise of temperature, and
especially the characteristic desquamation of the palmar surface
of the hands, left no doubt as to the correctness of the diagnosis.
The urine never contained albumin, and the temperature was
seldom higher than 102° F. Dr. Langmann also stated that it
was not rare for a patient to have scarlatina more than once.
Dr. William Balser had observed a case in which the pa-
tient had six attacks of scarlet fever.
Dr. Herman G. Klotz said it was important to remember
that erythema exudativum occurred most frequently in the
spring and autumn, and also called attention to the fact that,
after an exanthema brought on by quinine, a desquamation of
the palmar surface of the hands occurred.
A. Seibert, M. D., Secretary pro tern.
Meeting of December 28, 1883.
Dr. Ernst Schottky in the Chair.
Calcareous Concretions in the Sputum.— Dr. Aug. Seibert
exhibited three calcareous concretions which, at various times,
had been coughed up by a patient who had marked dullness at
the apex of the left lung.
The patient stated that be had experienced a pain at a cer-
tain point of the thorax, which began a certain time before he
had coughed up these deposits. This pain ceased as soon as the
deposits were coughed up.
Interstitial Pregnancy and Rupture of the Uterus.— Dr.
II. J. Boldt exhibited the uterus and appendices of a woman,
twenty-one years of age, with the following history : Five days
before death, while dressing to go out for a walk, she was sud-
denly seized with intense pain in the right inguinal region
which compelled her to go to bed. She stated that she had
danced on the previous day. "When Dr. Boldt first called he
found the patient very pale, semi-comatose, and complaining of
very severe pain in the right inguinal region. The uterus was
anteflexed. Twenty-four hours later peritonitis set in. On the
fifth day she vomited frequently, the temperature rising to 103°
F., and on the following night she died.
At the autopsy about twenty ounces of coagulated blood
were found in the right pelvic cavity. This blood apparently
took its origin from the posterior surface of the uterus, where a
laceration was visible, and at this point a swelling was also
found. ►
Dr. Boldt thought that the ovaries were in a state of cystic
degeneration.
Dr. J. Kuoiier was of the opinion that Dr. Boldt's case
was one of interstitial pregnancy, and that the swelling found
on the uterus was probably placenta.
Dr. H. Garrigues was of the same opinion as Dr. Kucher,
and did not think that the ovaries were degenerated, but that
the right ovary, which apparently was degenerated, simply con-
tained a corpus luteum.
Cheesy Degeneration of the Lungs. — Dr. Boldt also ex-
hibited the lungs of a child which he had presented to the meet-
ing on February 23, 1883. Craniotabes was diagnosticated at
that time. The lungs contained cheesy deposits. The bron-
chial glands were enlarged.
Tuberculous Meningitis of the Convexity of the Cere-
brum.— Dr. A. Jacobi exhibited the convexity of the hemi-
spheres of the cerebrum of a man fifty- one years of age, whom
he was called to see in consultation with Dr. Herzog on Decem-
ber 19, 1882. Dr. Herzog was called because the patient suf-
fered from a severe headache and complained of irritability.
His family history was negative. The pulse during the course
of the disease only sank as low as 64 beats on one occasion.
December 14th the patient was seized with spontaneous vomit-
ing. On December 19th, when Dr. Jacobi first saw the patient,
he found the left pupil considerably dilated. The naso-labial
fold had disappeared. The patient presented a typical case of
taches mining itiques. The heart and kidney were normal.
A diagnosis of tuberculous meningitis of the convexity of the
brain was made. The localization of the diagnosis was made
on account of the small degree of irritability of the pneumogas-
tric, which was demonstrated by the fact that the frequency of
the pulse was very little changed. The post-mortem confirmed
the diagnosis.
Sublimate Dressing.— Dr. H.J. Garrigues showed the sub-
limate dressings which he used with good results in the Mater-
nity Hospital.
Dr. J. Kucher considered the dressing superfluous, because
the infection occurred during parturition. This fact was proved
by the well-known immunity from puerperal fever in cases
where labor set in unexpectedly on the street.
Dr. J. Kudiscii pointed to the fact that previous to the intro-
duction of antisepsis a favorable result was frequently obtained
in the intervals of endemics of puerperal fever, and that a simi-
lar interval possibly occurred in the case of Dr. Garrigues when
he employed the antiseptic dressings.
Dr. A. Jacobi said that the type of puerperal fever prevail-
ing in the Maternity Hospital when Dr. Garrigues employed
the dressing was diphtheritic, and that the favorable results
observed by Dr. Garrigues occurred at a time when diphtheria
was prevalent in the surroundings of the hospital in the same
proportion as before the introduction of the sublimate dressing,
so that the favorable statistics now obtained must bear some
relation to the employment of this dressing.
276
MISCELLANY.
[N. Y. Med. Joub.,
Dr. A. G. Gerster remarked that he used a similar dressing
in lithotomy, and that this dressing prevented putrefaction of
the urine. A. G. Gerster, M. D., Secretary.
The International Medical Congress. — " Gaillard's Medical Jour-
nal " publishes the following letter from a correspondent who signs
himself " Old Code":
" Although not wishing to trespass upon space which might be
more profitably devoted by you to scientific material, I desire, never-
theless, to present for your consideration, in connection with the matter
of the Ninth International Medical Congress, several principles which
thus far in the discussion of that unfortunate subject seem to have
escaped general attention, and which, if rightly understood and applied,
would, I believe, set at rest much existing controversy. They are the
principles upon which the International Congress as an institution was
first conceived, and upon which, up to the present time, it has main-
tained a most successful career.
" I. The International Congress is essentially an independent, self-
perpetuating body. It is independent because its objects are purely
scientific, and its organization possible only upon that basis. It is self-
perpetuating because capable of appointing its own officers and of
electing its own places of meeting. Its hitherto uninterruptedly suc-
cessful career places the fact of its perpetuity beyond a doubt.
" II. The Congress is, as its name implies, distinctly international.
As an institution, therefore, it can not by any possibility be considered
the property of an individual, country, or part}-. Should such proprie-
torship be admitted at all, it could only be in the case of those who
originated the enterprise and who have conducted it through its eight
successful meetings. Since this is so, it would seem not only wise and
courteous, but, in fact, absolutely necessary, that local issues be placed
as far as possible out of sight.
" III. The profession of any given country in which a regular meet-
ing may be convened have certain privileges (as of entertainment, gen-
eral arrangement, etc.) committed to them, as it were, in trust. The
entertaining body has, of course, its own share in the governance of
the Congress as a whole, just as any other country represented, but it
can not possibly be conceded to have full controlling power. While
accepting and exercising in full the privileges accorded to us as the
organizers and entertainers of the Ninth Congress, we are still com-
pelled to recognize our trusteeship, and we are under obligations, when
we have finished with the institution, to leave it in the same sound con-
dition in which it was received.
" IV. It is, clearly, the whole body of the International Congress
which should dictate its policy. The expressed wish of the Congress
must be accepted, therefore, as the controlling line of action. When,
at Copenhagen, it was proposed that the next Congress be held in
Washington, before the question was put for decision to the Eighth
International Congress then assembled at its final general meeting, it
was distinctly understood by those in charge that political issues in
general, and the so-called ' code issue ' in particular, were not to be ad-
mitted. It was as plainly understood that the representation was to be
of llhe medical profession of America!1 Upon the strength of these
propositions the vote was carried unanimously.
" Thus, in the present condition of affairs, we appear before the
world not only divided against ourselves, but, what is far worse, as
having set aside the distinct compact made with the International Con-
. gress itself, having acted in direct defiance of the principles by which
it has heretofore been controlled, and having placed ourselves in clear
opposition to its expressed wishes.
''Regarded from the International, and, therefore, from the true
anil broad standpoint, questions relating to local politics, local organi-
zations, or local sentiments have in this matter no place. They are,
most absolutely, out of order.
" When the above principles are thoroughly understood by the pro-
fession of this country at large, and when it is also understood that it is
only upon them — that is, upon the principles of its own adoption — that
the International Congress will allow its policy to be conducted, we may
hope that the present dilemma may be removed and further disaster
averted. I trust that this most desirable issue may await us in the
very near future."
The " Medical Times and Gazette," of London, says :
"The 'Lancet' has not taken up a wise line in reference to the
Washington Congress. It has either been misinformed as to the facts
and the importance of the unfortunate dispute now going on in Ameri-
ca, or else it has willfully shut its eyes to them. It is absurd, for in-
stance, of the ' Lancet ' to attempt to minimize the differences which
have caused the withdrawal from the Congress of almost every man of
mark in America. The fact that nearly every medical journal of any
repute in the United States has vigorously condemned the action of the
American Medical Association, and given its warm support to the men
who are contending for the freedom of the profession against the selfish
designs of a clique, should in itself have induced the ' Lancet ' to give a
little more attention to the question before taking the wrong side with
such a light and careless heart. The sole fact that seems to weigh with
the ' Lancet ' is that Dr. Flint has been appointed President of the
Congress, or rather that his original appointment has been confirmed
by the new committee. Dr. Flint's is no doubt a powerful name to
shelter one's self behind. Be is incontestably one of the most eminent
representatives of the profession in the United States, and it has been
a source of profound sorrow to those who have felt constrained to with-
draw from the Congress that in doing so they have had to part com-
pany with him. But we can not blind ourselves to the fact that Dr.
Flint, eminent and honored as he is, has in the present instance allowed
himself to be made the instrument of a minority. The part which Dr.
Flint would take in this lamentable strife has been foreseen and dis-
counted. The men of Boston, Philadelphia, and Baltimore who with-
drew from the Congress knew that he would not follow them. The
fact is that Dr. Flint is bound up with the American Medical Associa-
tion, and an honorable feeling of loyalty no doubt constrains him to
accept its decisions, however much he may deplore them in his secret
heart.
" If the British Medical Association — a body five times more repre-
sentative of the English profession than the American Medical Asso-
ciation is of the profession in the United States — had played the same
part in reference to the London Congress that the American Associa-
tion is attempting to play in connection with the Washington Congress,
the 1 Lancet ' would not have been able to find language strong enough
to use in condemnation of such action, and we are simply at a loss to
understand the reasons which have actuated its present policy. Surely
the ' Lancet ' can not have realized the fact that the American Medical
Association — i. e., a body representing only ten per cent, of the pro-
fession in the United States — has decided that no American practitioner
shall be admitted to the Congress who is not either a member of the
association or a delegate appointed by a State or county medical soci-
ety. In other words, if the American Medical Association has its way,
between thirty and forty thousand American practitioners will be kept
as much outside the Congress as if they were not medical men at alL
Is the 1 Lancet ' prepared to give its support to a narrow and illiberal
innovation of that sort ? Would our contemporary be surprised to
learn that this question of principle will henceforward form the main
ground of conflict ? It may be answered that any American practitioner
can purchase the right to become a member of the Congress by joining
the American Medical Association. True, but will the foreign visitors
let the Congress be thus turned into an instrument for forcing men to
join the association who would not join it of their own free will ? It
is evident that on this question all the leading men who have with-
drawn from the Congress will be on the same side with the thousands
of practitioners who are at present outside the American Medical As-
sociation. And on the other side whom have we ? Dr. Flint, the wire-
pullers of the association, and the ' Lancet.'
" We are very sorry that our contemporary has committed itself to
that side, which every one who knows the facts and judges them with
sobriety must admit to be the wrong one. Its American readers will
Sept. 5, 1885.1
MISCELLANY.
277
scarcely welcome such ill-timed and ill-instructed advocacy. The only
hope for the Congress lies not in a postponement of disputes till after
it is over, but in an unconditional surrender by the American Medical
Association of the position which it has so unwisely taken up, and in
the rehabilitation of the original committee. On these points we be-
lieve that the leading men who have retired from the Congress are
unanimously determined, and will admit of no compromise. If they
still stand aloof, there will be no Congress, in spite of the ' Lancet's '
confident prophecies. Our contemporary seems hardly to realize the
extent and importance of the withdrawals. To take one section alone,
that of ophthalmology, not more than four or five men of any reputa-
tion are left on it. Dr. Agnew, Dr. Knapp, and Dr. Jones, of Chicago,
have been removed from their offices by the new committee of the
American Medical Association, while Drs. Thomson, E. Williams, Bur-
nett, Derby, Norris, Seely, Theobald, Wadsworth, and H. W. Williams
have all declined to hold office in connection with it. A similar state
of things prevails in almost every other section, so that, unless the
practitioners who have withdrawn can be induced to return, the Euro-
pean guests who go to Washington in 1887 in search of scientific dis-
cussion will have to provide it for themselves. Under such circum-
stances, we doubt if many will care to encounter the discomforts of the
Atlantic passage."
The "Journal of the American Medical Association " publishes the
following letter from Dr. John H. Packard, of Philadelphia :
"In an editorial in your issue of August 15th it was stated, on
what authority I do not know, that I had withdrawn my declination of
the secretaryship of the International Medical Congress of 1887, and
consented to assume that office. The truth is that up to the present
moment no official notice of such nomination has been sent me, nor has
any publication of it been made to my knowledge, except in the ' Medi-
cal News ' for July 4th. I do not, however, wish to make any point of
this, but beg that you will afford me space for a plain statement, as
brief as I can make it, of the facts in regard to this matter.
"On or about the 1st of June the chairman of what is now known
as the enlarged committee told me that Dr. Billings would probably de-
cline the office of Secretary-General, and asked me if, in that case, I
would accept the nomination. I told him I would not seek any office,
but that if it should appear to be for the promotion of harmony and of
the success of the Congress, and the nomination were offered me, I
would seriously consider whether I could undertake the work.
"After the enlarged committee had met in Chicago, a meeting of
physicians was called here to receive a report of what had been done.
I was at this meeting for a few minutes only, and did not hear the re-
port, or know that it concerned me. Subsequently I was told that my
nomination as Secretary-General had been announced, and that the im-
pression had been conveyed that I had been a party to ousting Dr. Bil-
lings in my favor — in other words, that I had intrigued to obtain a place
not vacant. I have since been told by the secretary of the committee
that my nomination came from an outside source, and without any
prompting on the part of those with whom I might have been supposed
to be in league. How any one who knew me should think me capable
of action so completely at variance with my whole life I could not and
can not understand. Yet I found myself under this imputation, and
felt compelled to subscribe my name to the protest of June 29th, lest
my not doing so should give color to the idea that I had so schemed.
" There was another reason, not of a personal character, for my
joining in the protest. The enlarged committee had adopted a rule
which limited the conditions of membership, so far as Americans were
concerned, while it left to foreigners free and untrammeled admission-
Of this I could not approve. I at once wrote to the secretary of the
committee and declined the nomination as Secretary-General, in advance
of official notification, on the grounds that I was informed that Dr.
Billings had not intended to resign, but had done so only because of
the action of the enlarged committee ; that the committee originally
appointed had resigned ; and that it was likely that the change of man-
agement would cause forfeiture of the foreign support of the Congress,
as well as of much of that expected from the profession in this coun-
try. This letter I have not withdrawn.
" When I understood that there was hope of a compromise being
effected in regard to the matters in dispute, and the propositions look-
ing thereto were shown me, it seemed to me that they were faulty in
that they dealt with the American membership only ; and I ventured
to submit one simply defining the conditions upon which any one,
American or foreign, might come in. In handing this to Dr. Shoe-
maker I gave him also a note of explanation, in which I said that if
anything better was offered I would gladly accept it. So far as I know,
this was the only expression of mine which could be construed into a
withdrawal from my former position.
" My own conviction is that it is contrary to all precedent for the
American Medical Association to assume any control of the manage-
ment of the Congress, which is a body by itself, and the members of
which will be in no sense the guests of the association, or subject to
it. Were I Secretary-General of the Congress I should not consider
myself the appointee of the American Medical Association, nor re-
sponsible to it in any degree.
" And while it is eminently proper that the profession all over the
country should be welcomed to membership in the Congress, and to a
full share in its proceedings, the association does not seem to me to
be, in its present form, a sufficiently representative body to undertake
to insure this, even if it could properly claim the right to do so.
" I trust that you will bear with me in what is perhaps the
wearisome length of this statement of facts and opinions ; but it has
seemed to me to be due not only to myself, but to those who have
been kind enough to consider me worthy of nomination to office in the
Congress.
" No one can regret more than myself the prospect of wreck of a
scheme in which the credit of the American profession is so deeply in-
volved ; and to avert it I would gladly do all in my power, but can not
sacrifice my personal honor or stifle my convictions."
The " Medical Record " says :
" The ' Journal of the American Medical Association,' which has so
steadily maintained a character for dignity and dullness, has recently
lost its first attribute at least, without perhaps undergoing much change
as regards the second. Its endeavors to prop up the present managers
of the International Congress have led it into a curious position. It is
no longer the organ of the profession, or even of the association, but is
rather a strident defender of the clique who are bent on having their
own way. Despite the almost universal condemnation of the policy
developed at New Orleans and Chicago, the ' Journal ' continues to de-
fend it. In doing so, it has not had the courage of other journals,
which it accuses of being 'organs,' but has systematically repressed all
adverse critical comments even from disinterested European brethren.
It has sneered at the eminent gentlemen who have withdrawn from the
association, and has characterized them as thoughtless and foolish mal-
contents. Although resignations have now been going on steadily for
over two months, it still chooses to regard the action as ' hasty.'
" With all this, however, we are each week informed that, if the
withdrawing members will hurry up and return to the fold, it may not
yet be too late for them to be forgiven ! The ' Journal ' is in much the
position of a man on a raft, who threatens the passengers of a stanch
ship with all the dangers of the sea if they do not soon come down and
help him navigate.
" Last of all, the ' Journal,' to help itself along, has been guilty of
misstatements, which, however, we can easily believe were accidental or
typographical. We quoted last week from it the announcement that
Dr. John H. Packard had withdrawn his resignation. We have the
authority of the ' Medical News ' that this is not true.
" Our Chicago contemporary, in discussing the question, has in
every instance evaded the real issue, viz., that there should be no poli-
tics in a scientific convention. The introduction of this issue it can not
excuse, and wisely has not attempted it.
" From its last announcement, we infer that no serious attempt at
compromise is to be made. The present managers will, it is true,
change the rules so that any regular physician can be a member of the
Congress. But it is simply an insult to intelligence and self-respect to
assume, as is done, that this is any concession. Gentlemen of new-
code affiliations can contribute in money and work, but can not share
the honors !
" There is a demand from the whole American profession, from that
of England, Germany, and the other countries of Europe, that the code
278
MISCELLANY.
[N. Y. Mkd. Joes.,
issue be entirely left out. Will not the committee, which is to meet in
this city on September 3d, respond to this demand ? It would not be
very difficult, and the success of the Congress would then be assured."
Vaccination after the Beginning of Small-pox. — As we have taken
the ground that this practice is useless, we think it only fair to give
heed to respectable testimony to the contrary. We therefore quote the
following letter, addressed to the "Lancet" by Francis J. Allan, of
Edinburgh :
"On the evening of April 12th last I was called to see C. R , a
domestic servant, aged twenty years, with the following history : She
had come to this situation on April 1st, feeling well, but at the end of
a week she began to complain of lassitude and headache, and on the
10th and 11th these were accompanied by sickness and pain in the
throat, back, and limbs. On the 12th a few papules appeared on the
forehead, neck, and body, and on the legs were large red patches.
When seen in the evening the girl said she was 'all right, except for
the spots.' From the symptoms and the character of the papules a
mild form of small-pox was diagnosed. The girl was removed next
day to the small-pox hospital, and the other inmates of the house were
revaccinated. C. R 's fellow-servant, C. L , eighteen years of
age, who had occupied the same bed up to the 11th, complained at the
time she was revaccinated of loss of appetite, and her arms were no-
ticed to be rough, which she said was unusual. Next day (the 14th)
she had severe pain in the back, the tongue was thickly furred and the
fauces inflamed, with four small painful raised spots visible ; tempera-
ture in right axilla 103° F. The patient had been excited and delirious
during the night. On the 1 5th several papules were seen on the face,
and the pain was not so severe. Meanwhile the left arm was becoming
red and swollen at the seat of vaccination, which was evidently 'taking.'
On the 16th the hard papules on the face were disappearing, and the
skin of the legs and arms was desquamating slightly. The pain in the
back continued until the 19th, by which time large vesicles had formed
on the vaccinated arm, the four large pocks looking more like the re-
sult of a primary than a second vaccination. In a couple of days the
pocks were at their height, and, with the exception of some swelling
of the axillary glands and general weakness, the patient felt compara-
tively well. The skin very soon became clear and smooth, and she was
able to resume her usual employment in a fortnight from the first ap-
pearance of the small-pox symptoms. On the others (four persons) in
the house the vaccine took full effect. No other cases of small-pox
have occurred in the house or vicinity since.
"No cases of small-pox had been known in the neighborhood for
several months ; and, as the incubation stage is of about twelve days'
duration, it was presumed that C. R had been exposed to the in-
fection previously to her taking the situation on April 1st. On the
12th the papules appeared, so that, allowing two days for the stage of
invasion and twelve for that of incubation, it is probable she was ex-
posed to the infection about March 29th. C. L slept in the same
bed with C. R until April 11th, and, making the same allowances,
possibly the poison entered her system the first night C. R slept
with her. Even if the stages were shorter, it still shows that the in-
fection may be communicated at a very early stage of the disease. A
more important point is the action of vaccine as an antidote to small-
pox. It has been asked, Is it worth while to vaccinate a patient who
is beginning to show symptoms of small-pox ? This case (C. L 's)
answers the question to the effect that small-pox may be checked, if
vaccination be done with good lymph, even as late as the end of the
incubation stage or the beginning of that of invasion. In this case,
from the seventy of the prodromal symptoms, the attack of small-pox
would have been a correspondingly severe one; and this is borne out
by the large typical vaccine vesicles produced, showing the great sus-
ceptibility of C. L to the small-pox poison. Evidently, it was the
more rapid development of the vaccine which saved the patient from
a virulent attack of the more slowly growing small-pox."
A Reminiscence of the Royal Society. — T. Wharton Jones, F. R. C.
S., ¥. R. S., treats the readers of the " Lancet " to a recital of the part
which he played, some fifty years ago, in the investigation of the ova-
rian ovum. He recounts having combated " the erroneous views of the
late Dr. Martin Barry .... which were promulgated with the support
and encouragement of the ' Royal Society of London for promoting
Natural Knowledge' and of all the ' scientific world of London' — that
is, a clique of the professing physiologists in London, who had got vir-
tual possession of the Royal Society, and arrogantly pretended to decide
what ought and what ought not to be considered facts in nature with-
out themselves knowing anything whatever of the subject, for lack of
original investigations of their own." Our author writes under the fol-
lowing noteworthy caption : " On the Ova of Man and the Mammifera
before and after Fecundation. Historical Notice of the Discovery of
the Germinal Vesicle of the Mammiferous Ovarian Ovum, and of the
Recognition of a Superadded Investment around the Ovum of the Rab-
bit as it Presents itself in the Fallopian Tube after Impregnation : a
Single-handed Struggle against the whole so-called 'Scientific World' of
London Fifty Years Ago. Dedicated to the Scientific World of the
Present Day."
The " Journal of the American Medical Association." — In the
course of an editorial article entitled "The International Medical Con-
gress and the American Medical Association," the "North Carolina
Medical Journal " says : " We trust that, whether we have an Interna-
tional Congress in the United States or not, the dilemma now puzzling
the wisest men in the American Medical Association may be overcome,
and that such safeguards may be devised as will give the smallest scope
for medical politics in the future. It is almost marvelous that such a
threatening condition of things was never before reached when one
analyzes a few of the huge meetings of the association. It is evident
now that, in the future, the opportunities for medical politics must be
reduced to a minimum, and every effort made to make the production
of scientific work the chief object of the association and a test for pre-
ferment. We do not sympathize at all with the suggestion that a new
national society should be formed. Secession is a costly business — it
arrays good friends against each other, consumes valuable substance,
and is so liable to end at last in striking colors you have pride in, and
in grounding your arms to an enemy having the only advantage over
you in being more numerous and better fed. For these and other rea-
sons we prefer to encourage every means which will make the American
Medical Association what the British Medical Association is, and we
believe that the surest means to this end is to build up the journal of
the association ; for no one can doubt, although of late some of the
editorials on the Congress have been acrimonious, that the editor has
all the qualities of an earnest heart."
Homoeopaths and Homoeopaths. — We find the following in a very
interesting presidential address, entitled " The Latest Systems in Medi-
cine," lately delivered before the Ohio State Medical Society, by Dr. J.
C. Reeve, of Dayton :
"The diversity of homoeopathic doctrines shows that the term
' homoeopath ' does not define a man's position with any accuracy at all.
It covers very diverse, even opposite opinions. This fact has an impor-
tant bearing upon the medical politics of the present. You know that
our sister society of New York has been divided upon the question of
consulting with homoeopaths. It would be well for us, therefore, so
long as this question remains a possible one for this and other societies
to consider, to understand as clearly as possible what the term ' homoeo-
path' implies.
" It includes, at least, three distinct and well-defined classes : A few
homoeopaths are Hahnemannians. At the meeting of the New York
Homoeopathic Society in 1883, three acknowledged themselves to be
such out of sixty present. According to the ' British Medical Journal,'
the real homoeopathists of Great Britain can be counted on the fingers
of a single hand. With this portion of the sect it is impossible to con-
sult. You can not reason with a man who maintains that a part is
greater than the whole. These are intellectual cranks.
" A considerable larger portion of the sect is made up of those who
have been educated in all the branches of medical science, who practice
in good faith according to the law of similars, but who are bound by
no rigid rules as to dose. This class is more numerous in Eastern cities
than here. It is large enough to have an organ. This journal carries
at its head this extract from our code of ethics : ' A regular medical
education furnishes the only presumptive evidence of professional abili-
ties and acquirements, and ought to be the only acknowledged right of
Sept. 5, 1885.]
MISCELLANY.
279
an individual to the exercise and honors of his profession ' ; and this :
' Our practice is -not based on an exclusive dogma, to the rejection of
the accumulated experience of the profession, and of the aids actually
furnished by anatomy, physiology, pathology, and organic chemistry.'
" These men comprise the best of the sect. They support medical
legislation to establish boards of health and insure to the public edu-
cated physicians. They are on their way back to the ranks of the pro-
fession ; they are dropping their distinctive appellation, and certainly
no obstacles ought to be placed in the way of their return. It is folly,
and worse, to call them charlatans and quacks. They are men who
exaggerate the value of the law of similars, and the efficacy of the
small dose. There is room for honest difference of opinion as to the
range of the law, and it will not do for men who use ' Ringer as a text-
book to be too particular about small doses. These men are but little
farther from the general line of practice than many of our number who
ride ' hobbies,' who appear so frequently in the journals with new and
wonderful modes of treatment of diphtheria, scarlet fever, or of some
other epidemic they have passed through. We smile at the enthusiasm
of these men, we recognize their error to be the same as that of the
system-makers, generalizing from a few facts, we glean from their
bushel of chaff the few grains of truth there may be ; we do not cut
them off from professional fellowship. We ought to treat as profes-
sional brethren all men who have been educated in medicine, who are
honorable in conduct, who elevate the profession above any of its sects,
who are honestly trying to advance our knowledge, and to cure disease
and alleviate suffering, whatever may be their methods.
" The majority of homoeopaths are unfortunately of quite another
character. They have adopted this line of practice for whatever there
mav be of popularity in it, and they pursue their calling in the sole
spirit of trade. Shall I be charged with slandering my neighbors ?
Hear what the ' Medical Times ' says. It has dropped the distinctive
title of ' homoeopathic,' and advises others to do the same : ' We are
as confident as we can be of anything that many use the term from
mercenary motives, and that it is in many instances only a trade-mark ! '
The editor says further that the reply to this advice always is that
practice would be lost in doing so : ' With this fact in view, how can
we reach any other conclusion than that the title is retained for the
purpose of business ? ' In plain English, this means that they are ob-
taining money by false pretenses. These are the men who have kept
bright the spirit of the founder — hatred of the regular profession.
They habitually indulge in the grossest misrepresentations of regular
practice, and play upon every prejudice which exists, or which they can
excite, in the public mind. They sneer about ' drugs.' It is a good
word to use ; it sounds like dregs, and dregs means dirt. They boast
much of using ' pure medicines,' thereby conveying the slander that
others are not careful about the quality of the chemicals they adminis-
ter. They instill into the minds of their patrons the fear of ' strong
medicines,' and, while doing so, deal out ' lachesis ' (serpent venom) and
' crotalus ' (the poison of the rattlesnake) — medicines which are too
strong for our pharmacopoeia. They emphasize the single-medicine
doctiine while dispensing several different kinds to be given at intervals
of ten or fifteen minutes. These are the men who prate of being the
' advanced thinkers ' of the age, implying that no one else is trying to
extend the knowledge of cure of diseases, while they bitterly oppose
all efforts to enforce thorough medical education. These are the men
who, to prevent the establishment of boards of health, go to the pub-
lic and whine about ' class legislation ! ' These are the men who are
homoeopaths in one house, and in the next are anything that will suit.
With these men we can not consult. We want a basis of common
honesty, at least, to say nothing of that dignity and education which
should attach to a profession which deals with the dearest interests of
humanity. We must treat them as we do those of our own practice,
who, with unblushing impudence, placard the walls and fill the columns
of the daily papers with boasts of their superior skill and false state-
ments of cure.
"But all members of our profession who advocate consulting with
homoeopaths may set their minds at rest. The homoeopaths do not
want us to consult with them. When we decline to meet them, there
is a loud outcry about professional intolerance and bigotry and perse-
cution. But during this great movement in the State of New York to
terminate this schism and bring about common consultations, not a
motion in its favor was made on their side of the house. I have looked
carefully through the files of their journals, but failed to find one word
of friendly advance. Of course, schisms and sectarianism do not ele-
vate medicine, or increase respect for it, any more than they do religion.
It were better if this division was closed. But, judging from the spirit
of the times, it will be a long time before this sect disappears. The
better portion of the homoeopaths make no organized effort toward re-
union ; those who ply it merely as a money-getting calling will never
leave it as long as principles and prejudices exist in the human mind
which make it profitable."
The Canada Medical Association. — We learn from the " Canada
Lancet" that the following are the papers promised up to the 19th ult.
for the Chatham meeting: Dr. Osier (Philadelphia), " The Clinical and
Pathological Relations of the Ca;cum and Appendix " ; Dr. A. Grant
(Ottawa), "Aortic Aneurysm, with a specimen"; Dr. W. B. Geikie
(Toronto), "Retroversion of the Gravid Uterus"; Dr. Burt (Paris),
" Internal Urethrotomy " ; Dr. Holmes (Chatham), " Puerperal Mania " ;
Dr. Kerr (Winnipeg), "Fractures in the Neighborhood of Joints" ; Dr.
Fenwick (Montreal), "Amputation of the Breast, with cases"; Dr.
Bethune (Wingham), exhibition of specimens: 1. "Parasite from an
Abscess of the Thigh " ; 2. " Aneurysm of the Pulmonary Artery " ;
Dr. Worthington (Clinton), " Epidemic Cerebro-spinal Meningitis " ;
Dr. Fulton (Toronto), " Subperiosteal Amputation " ; Dr. Campbell
(Seaforth), " Trephining the Mastoid Bone " ; Dr. Rutherford (Chatham),
"Supra-pubic Urination"; Dr. Lett (Guelph), "Inebriety, a Disease
the Result of Physical Causes " ; Dr. A. H. Wright (Toronto), " Phleg-
masia Dolens " ; Dr. McKeough (Chatham), " Pilocarpine in Puerperal
Eclampsia"; Dr. J. E. Graham (Toronto), "Dissecting Aneurysm of
the Thoracic Aorta, with specimen"; Dr. Shepherd (Montreal), "Ex-
cision of the Tongue"; Dr. Alio way (Montreal), "Puerperal Septicae-
mia " ; Dr. Ryerson (Toronto), " Atrophic Nasal Catarrh " ; Dr. Ather-
ton (Toronto), " Abdominal Section for Uterine Myomata " ; Dr. Nat-
tress (Toronto), "Field Hospitals in the Northwest Territory " ; Dr. A.
E. Hanna (Lansdowne), " Enlarged Prostate " ; Dr. Gardner (Montreal),
" Double Uterus, with specimen " ; Dr. Oldright (Toronto), " Pernicious
Anaemia " ; Dr. Ames (Brigden), " Rattlesnake Bite " ; Dr. Wilkins
(Montreal), "Specimens illustrating the Infective Nature of Tubercu-
losis " ; Dr. Stewart (Montreal), " The Curability of Chronic Infantile
Paralysis."
Ominico. — Mr. Stanley W. Neuer, the manufacturer of this new
disinfectant preparation, has received the following letter from Dr.
Edward R. Mayer, of Wilkesbarre, Pa. :
"Since you have made known to the public the constituents of
your ominico compounds, there is no longer any objections to my reply-
ing to your request for a brief statement of the experiments made with
it by me and of their results.
" This compound, which is a scientifically prepared solution of bora-
cic acid, chlorate of potassium, chloride of sodium, and thymol, pos-
sesses active properties as a disinfectant and as an alterative to in-
flamed cutaneous and mucous surfaces. I have used it with excellent
effect in many of those diseased conditions of the mouth, throat, and
nasal passages in which Listerine and phenol sodique have been hither-
to employed by medical men, and I regard it as not only a safe and very
agreeable mouth-wash, gargle, and application for spraying, but as one
having great efficacy in many cases of catarrh, sore throat, cankers, and
in some chronic skin affections."
Dr. J. A. Murphy, of Wilkesbarre, writes as follows :
" I carefully indorse every word Dr. Mayer says of your ominico
aseptine compounds, and will simply add that, after using almost every
remedy recommended by the profession for the past ten years in the
treatment of chronic nasal catarrh, I have found nothing so agreeable
and to afford so much relief as your compound."
Sanitation and Milk. — The production, care, and handling of milk
and its preparation for the market under the observance of the most
rigid sanitary and hygienic conditions is a subject to which the medical
profession has, so far as we know, given but little if any attention.
These conditions, so essential for the production of a pure grade of
280-
MISCELLANY.
[N. Y. Mkd. Johh.
milk, are beyond the facilities of the ordinary milk-producer, involving,
as they do, regulating and watching the physical condition of the cow ;
the quantity and quality of her food ; the cleanliness of the stable ; the
entire absence of everything giving rise to odors in the dairy — as milk
readily absorbs and retains any smell, such as that of rancid milk, ma-
nure, tobacco, etc. — the proper and careful cooling of the fluid ; and,
lastly, the complete disinfection and cleaning of cans or bottles in which
it is sent to the consumer.
A recent visit to the dairies of the " Echo Farm Company," situated
in [the towns of Litchfield, Bantam, and Washington, Conn., demon-
strated to us the possibilities in this direction. There absolute cleanli-
ness is the rule and not the exception. The milk, as it is received
from the various farms, is carefully strained into cooling tanks, in
which the temperature is reduced to about 55° F., in which condition
it is drawn into bottles that are hermetically sealed and packed in ice
for the market. Tests of the cream-producing qualities of the milk are
made weekly — the average being from 15 to 17 per cent. A competent
medical man makes frequent and thorough inspections of the cows,
their food, and the sanitary condition of their stables, and nothing that
sanitary and hygienic laws can demand for the production of an abso-
lutely pure milk is left undone.
THERAPEUTICAL NOTES.
Napelline in the Treatment of Odontalgia. — Grognot (" Bull. gen.
de therap.") gives brief notes of a number of cases in which he has
used Laborde and Duquesnel's napelline, which, being obtained from
Acomium napelhis, is to be distinguished from the substance to which
Groves gave the same name, but which he extracted from Aconitum
ferox. The author's plan was to give a granule of half a centigramme
( = about -075 of a grain) by the mouth every fifteen minutes. Notes
are given of six cases, in only one of which did no notable improve-
ment take place. Usually the pain was stopped or greatly mitigated
by the time four or five doses had been taken. One of the cases was
of two years' standing.
Salicylate of Cocaine in the Treatment of Trigeminal Neuralgia.
— Schneider (" Allg. med. Ctrl.-Ztg." ; " CtrlbL f . d. ges. Therap.") re-
lates the case of a woman in her third attack of neuralgia of the
second and third branches of the trigeminus. The first attack, five
years before, had been treated successfully with large doses of quinine.
The second attack lasted almost six months ; quinine was of no avail,
but the pain gradually disappeared under the use of morphine and iron.
The third attack had continued four weeks when the author injected
salicylate of cocaine experimentally. The effect was extraordinary ; six
grains of the salicylate, injected into the cheek, caused the pain to dis-
appear entirely, and occasioned a general feeling of well-being wholly
free from any unpleasant collateral phenomena. The injection itself
was painless and did not give rise to irritation. The patient was
enabled to sleep at night, although before the pain had been most se-
vere at night. Eight such injections were given in the course of six
days, and after that there was no pain except at the site of the injec-
tions, which was overcome by three applications of galvanism with the
anode applied to the seat of the pain and the cathode to the back of
the neck.
The Dose of Codeine. — Schneider (Ibid.) contends that the usual
doses of codeine and its salts are quite ineffectual. In about thirty
cases he has used it in doses ranging from a grain and a half to three
grains, with the result of producing sleep for four or five hours or for
the entire night, and without any unpleasant effects, except vomiting
in one instance. He regards the drug as a great boon for victims of
the morphine habit while they are under treatment, acting as a substi-
tute and a palliative. In such cases he gives a grain and a half every
three hours.
Resorcin in the Abortive Treatment of Gonorrhoea. — A. J. Mun-
nich, of Amsterdam ('' Monatsh. f. prakt. Dermat." ; " Ctrlbl. f. d. ges.
Therap."), has been led by a suggestion of Andeer's to try the effect of
injections of resorcin in the treatment of gonorrhoea. He began with
a two-per-cent. solution, but, being dissatisfied with the results, soon
proceeded to the use of a three-per-cent. solution. One hundred and
eight cases were treated ; sixty-seven successfully, and forty-one unsuc-
cessfully. The method was as follows: The patients were told to
drink as much water or milk as they could, so as to be able to wash the
pus out from the urethra by urinating before each injection. The pa-
tients managed the injections themselves, taking one every two hours
by day and two during the night, and they were instructed to let the
liquid flow out from the urethra at once. They usually reported on the
fourth or fifth day, and in most cases the discharge was very decidedly
diminished where it had been profuse, or at least not increased where
it had not been copious from the start. When the night injections
were omitted, the improvement of the day before was usually lost, and
the duration of the case was lengthened. The injections were now
reduced to three or four during the day and one at night, and in gen-
eral, in the cases recorded as successful, the discharge was exceedingly
slight on the seventh day, and had entirely disappeared on the four-
teenth. In the cases set down as unsuccessful, i. r., in which the dis-
charge became prolonged or the deep part of the urethra was affected,
at least the acute symptoms were always rapidly overcome. In only
one instance was it necessary to discontinue the use of the injections
on account of inflammatory symptoms, and in that case the patient had
retained the solution too long in the urethra. The quickest and best
results were obtained when the patients presented themselves soon
after the appearance of the disease. The author thinks that still better
success might be achieved in many cases by means of absolute rest and
perhaps irrigations with weaker solutions.
Piscidia Erythrina in the Treatment of Dysmenorrhea. — " Nou-
veaux reraedes " gives the following formula :
Mint water 120 parts;
Tincture of Piscidia erythrina 8 to 12 "
Syrup 30 "
A tablespoonful to be taken three or four times a day.
Scopolia Luridus. — According to Waring (" Pharm. Jour." ; " Nou-
veaux remedes "), this solanaceous plant, which is found at Nepaul and
in the Himalayas, is equal if not superior to belladonna as a mydriatic.
A tincture, made with one part of the leaves to eight parts of alcohol,
causes such a dilatation of the iris that in two cases it gave rise to
blindness, which did not disappear until the use of the drug was dis-
continued. The largest amount thus far given in twenty-four hours is
twenty drops. The author recalls Christison's experiments with the
drug.
Iodized Phenol in the Treatment of Whooping-cough. — Rothe
(" Memorabilien ") announces his continued satisfaction with carbolic
acid as a remedy for whooping-cough, after fifteen years' experience
with it. The formula employed is as follows :
' \ each 7£ grains ;
Alcohol, )
Tincture of iodine 5 drops ;
Peppermint water 750 grains ;
Tincture of belladonna 15 "
Syrup of diacodium 150 "
A teaspoonful is to be given every two hours, the administration
being continued until the paroxysms entirely disappear.
Salix Nigra as a Sexual Sedative. — Dr. F. F. Paine, of Comanche,
Texas (" Med. Age "), speaking from five years' experience with this
drug, states that during a practice of fifty years he has not used a rem-
edy that has yielded more satisfactory results. He recommends it par-
ticularly as an anaphrodisiac and as a remedy for ovarian irritation, in-
cluding certain cases of dysmenorrhcea. He gives teaspoonful doses of
Parke, Davis, & Co.'s fluid extract of the buds three times a day. He
thinks it has something of a specific action on the nerve supply of the
sexual apparatus in both men and women.
Buttermilk as a Remedy for Vomiting. — Dr. J. H. Owings, of Deer
Lodge, Montana (" Maryland Med. Jour."), states that he has used but-
termilk for the purpose of checking vomiting for ten or twelve years
past — in as many as fifty cases, he thinks — without a failure. He
knows of no other remedy equally satisfactory, and regards it as espe-
cially serviceable in cases of severe vomiting after a prolonged debauch.
Inodorous Iodoform. — The "Lancet" says that, according to M.
Gillette, iodoform may be rendered inodorous by adding 1 part of sul-
phate of quinine and 3 parts of charcoal to 100 parts of iodoform.
THE NEW YORK MEDICAL JOURNAL, September 12, 1885.
LECTURES ON
ELECTRICITY IN MEDICINE,
DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI-
VERSITY OF VERMONT, BURLINGTON,
By AMBROSE L. EANNEY, M. D., New Yoek.
{Continued from page 257.)
ELECTRICITY IN SPASMODIC AFFECTIONS.
Hyperkinesis is frequently encountered as one of the va-
ried forms of external manifestation of irritative and destruc-
tive lesions of the central nervous system. For example, it is
by no means uncommon to observe convulsions (of the clonic
or tonic type), tremor, muscular rigidity and contracture, etc.,
in connection with morbid changes in the brain and spinal
cord. By these symptoms we are often assisted in deter-
mining the seat of the lesion, although, as De Watteville
remarks, " the pathogeny of spasm is one of the most
obscure problems in neurology." On the other hand —
in many instances chorea, epilepsy, hysteria, etc. — spasm
may exist without any apparent structural changes in the
nervous system, being excited by some source of reflex irri-
tation— such as phimosis, visual defect, uterine displace-
ment, insufficiency of the ocular muscles, etc. In tetanus
the exciting cause is generally found in one or more of the
peripheral nerves. Sclerosis of the motor fibers of the lateral
columns of the spinal cord is known to produce muscular
contracture as a prominent symptom, probably because the
inhibitory influence of the brain upon the reflex excitability
of the spinal cord is arrested, or because the sclerosis di-
rectly excites the motor apparatus of the cord. The pe-
culiar deformities produced by post-paralytic contracture
and the eccentricities of gait and posture exhibited by pa-
tients suffering from tetanoid paraplegia (lateral spinal
sclerosis) are illustrative of the diagnostic value of tonic
muscular spasm in the course of some spinal affections.
Respecting the effects of electrical treatment of spasm,
I am convinced that in some cases many methods must be
tried without benefit before the right one is discovered.
I have occasionally had brilliant results follow some par-
ticular method, and subsequently I have been utterly disap-
pointed when it was tried upon some other patient with
identical symptoms.
I think that in this class of subjects more depends upon
your success in ascertaining and removing the cause than
upon any electrical applications (valuable as they may be as
adjuncts). The correction of an optical defect by glasses,
the relief of ocular insufficiency by tenotomy or prisms, the
operation of circumcision, the mechanical relief of a dis-
placed womb, and many other such procedures, form the
basis of an absolute cure in many cases which have been
otherwise treated unsuccessfully. This fact is too often
disregarded.
Electrical currents may be made to act upon these cases
(1) as a sedative (chiefly the action of the anode and static
insulation) ; (2) as a stimulant (the action of the cathode,
the static spark, or faradism) ; (3) as a counter-irritant ;
(4) as a check to the progress of some peripheral or cen-
tral morbid state (catalytic action) ; and (5) as an agent
for the destruction of some neoplasm, induration, etc. (elec-
trolytic action), or as a cautery.
I have lately come to regard static electricity (franklin-
ism) as more generally applicable to spasmodic conditions
(hysteria, torticollis, blepharospasm, tremor, contracture,
etc.) than either faradism or galvanism. It seems, in my
experience, to act more promptly, and to produce more last-
ing results, than the methods more commonly recommended
by authors. I would advise those of you who decide to
purchase a static machine to try the effects of insulation,
the " electric wind," and the indirect spark (as the circum-
stances may indicate) faithfully before you resort to galvan-
ization or faradization. If good results are not obtained, you
can easily substitute for it the other forms of treatment at
a later date. I should never regard any case as hopeless
until it had been thoroughly tried (after all reflex causes
had been removed). I have cured several severe cases of
tonic spasm of the muscles of the neck in a few sittings by
means of the indirect spark, and relieved many cases of suf-
fering from other forms of spasm in a short time.
In epilepsy, the employment of galvanism alone has
never, to my knowledge, resulted in a complete cure, al-
though some decided benefits have been reported from its
continued use. There is, to my mind, a close relationship
in many cases between epilepsy and ocular defect, to which I
shall call your attention hereafter. This element in the
causation of epilepsy certainly merits attention. When all
defects in the visual apparatus have been corrected (in case
such exist), or when other reflex causes (such as phimosis,
for example) have been relieved, galvanism and static elec-
tricity may become valuable aids in controlling the subse-
quent convulsive attacks. Latent hyperopia, astigmatism,
and insufficiency of any of the muscles of the eyeball may
(and, in my opinion, often do) excite epileptic seizures. It
is absurd to expect of electricity, or any other therapeutical
agent, curative results when so important a source of irrita-
tion of the central nervous system is allowed to remain un-
corrected.
Rockwell's method of employing " central galvaniza-
tion " in epilepsy does not, to my mind, equal in beneficial
effects the use of static insulation and the drawing of indi-
rect sparks from the neck and back of the patient. It is
my custom, however, in some cases to employ both of these
procedures, each being used alone during alternate weeks
for a period of two or three months with daily sittings.
In chorea I have obtained the best results with static
insulation and sparks.
My previous remarks respecting the relationship between
defects in the organ of sight and epilepsy apply with equal
force to this disease and all other types of functional- ner-
vous derangements. I shall discuss this subject more in
detail later in the course when functional nervous diseases
are being considered.
If galvanism is employed, it is best to subject the mus-
cles affected with spasm to the action of the anode. The
282
RANNEY: LECTURES ON ELECTRICITY IN MEDICINE.
[N. Y. Med. Jock.,
prognosis will depend somewhat upon the duration of the
disease. The earlier you begin electrical treatment, the
greater is the prospect of cure (provided all sources of reflex
irritation have been successfully removed).
My experience with faradism in the treatment of
chorea has been somewhat limited ; but the results obtained
by me have not been so satisfactory as with static electricity.
In facial spasm (histrionic spasm) good results are oc-
casionally obtained by following the plan of treatment sug-
gested in connection with chorea; but treatment of the
facial nerve alone is seldom satisfactory. I have one case
at present under treatment, however, in which I have thus
far had little, if any, success in my attempts to control the
spasm. It is a case of long standing, and is therefore more
rebellious to treatment than if it were not chronic. The
patient has an ocular defect which it is difficult to correct
perfectly.
In these cases I have obtained the best results by sub-
jecting both the cortical centers for facial movements and
the nerve itself to stabile applications of the anode (the
cathode heing placed on the breast-bone), and by treating
the nerve at intervals with static sparks drawn from the
affected portions of the face. The electrode for the head
should be large. The duration of each daily sitting should
not exceed five minutes.
Nystagmus and blepharospasm belong to the choreic
type of diseases, and are best treated by electrical currents,
provided they are seen before the condition has become
chronic. The prospect of a radical cure steadily becomes
less as time elapses. If static currents are employed, wooden
tips to the electrodes should be used. I usually treat these
cases as if the seventh nerve were involved in all of its
branches. Sometimes it is well to place the anode upon
the mastoid process and the cathode upon the closed eye-
lid. The current should be very weak at first ; should be
gradually increased until faint flashes of light are perceived ;
finally, it should be again decreased to the faintest percepti-
ble point.
Torticollis, or wry-neck, when subjected early to static
sparks or strong faradization, may often be cured very rap-
idly. Interrupted galvanic currents are also of material
benefit in some cases.
The spinal accessory nerve is usually the one which is
at fault. A rheumatic origin may often be detected. If
so, judicious medication will tend to hasten the cure.
Some cases of wry-neck are associated with symptoms
of paresis. These have, as you might suspect, a more
serious prognosis. Electrical treatment will prove, as a rule,
only palliative. Too often organic changes have already
occurred in the spinal accessory nerve, the spinal cord, or
the vertebrae. The duration of treatment should extend
over a period of months.
Spasmodic asthma may often be benefited by galvanism
of the neck. I have previously described the steps of this
procedure. Its beneficial effects are probably due to
changes induced in the vagi. Drawing of indirect sparks
(by means of the static machine^ from the anterior and
posterior surface of the chest has proved, in my experience,
an admirable preventive against such attacks.
Some patients have assured me that they experienced a
sense of great comfort after each sitting, and that the fre-
quency of the paroxysms of asthma has been perceptibly
modified by them. My experience in the electrical treat-
ment of these cases is as yet somewhat limited : but I
am inclined to believe that greater benefit can be derived
from it than from internal medication. Certainly it is
worthy of a more extended trial, as an adjunct, if deemed
wise, to other remedial measures, or as a substitute for
them.
In tetanus (both of the traumatic and idiopathic varie-
ties) two cases of cure have been reported by Mendel, of
Berlin. He employed galvanization and subjected the
muscles affected with spasm to the stabile influence of the
anode, the cathode resting over the spinous processes of
the vertebrae. The applications were continued for fifteen
minutes, and the currents employed were mild ones. Bar-
tholow suggests, when speaking of these cases, that the
effect of these applications was probably due "to the influ-
ence of the currents upon the sensory nerves, thus lessen-
ing the intensity of the reflexes." The cures were complete
in about ten days.
Personally, I have not as yet been able to test the effects
of the different forms of electrical currents upon a case of
tetanus. To my mind, it would be very interesting, how-
ever, to observe the effect of static insulation and static
sparks upon the spasms which occur paroxysmally in this
disease. It is well known that this agent exerts a remarka-
ble effect upon contracture of muscles. Thus far, to my
knowledge, it has never been tried in tetanus.
Sneezing, hiccough, and coughing are spasmodic ef-
forts of a reflex character. Occasionally they become dis-
tressing from their persistency. They may, in some in-
stances, be relieved by faradization of the epigastrium, gal-
vanization of the neck, and static electricity. De Watte-
ville reports some curative effects of galvanization of the
nasal mucous membrane in chronic cases of persistent
sneezing.
electricity in disorders affecting sensory nerve-
tracts.
The discovery that different bundles of fibers which
help to compose the substance of the spinal cord serve to
convey sensory impulses only, and the later researches
which have also been made respecting the paths of conduc-
tion specially prepared for sensations of pain, touch, tem-
perature, pressure, the muscular sense, visceral sensations,
etc., have a practical bearing upon both diagnosis and treat-
ment.
Clinical observations go to show that, of the separate
and distinct types of sensation enumerated, some may be
partially or completely destroyed by diseased conditions
without impairing the others. Thus, for example, a patient
under certain conditions may be able to exercise his sense
of touch with normal acuteness and yet be rendered abso-
lutely insensible to pain ; again, he may be unable to dis-
criminate between degrees of heat or cold (provided the
tests do not produce pain), although he retains unimpaired
sensory faculties in all other respects. We are, therefore,
Sept. 12, 1885.]
RAN NET: LECTURES ON ELECTRICITY IN MEDICINE.
283
forced to recognize a variety of types of anaesthesia as pre-
senting themselves for diagnosis and treatment.
The sensory functions may be either increased (hyper-
esthesia) or diminished (anaesthesia).
Either of these states may be of organic origin (by which
we mean that structural changes in the nervous tissues ac-
company them), or of purely functional origin, in which
case no structural changes can be shown to exist. Exam-
ples of the former are found in connection with central
lesions (those of the brain or spinal cord), and with peri-
pheral lesions of the sensory nerves or the organs of spe-
cial sense, while examples of the latter are frequently en-
countered in connection with hysterical conditions, neuras-
thenia, cold, injury, imperfect capillary circulation, rheu-
matism, neuralgia, and many other morbid conditions.
In all forms of sensory disturbance the removal of the
cause constitutes in many cases the basis of a cure, and the
treatment will necessarily be modified by the causal indica-
tions.
Many suggestions which have previously been offered
respecting electrical applications to the brain, spinal cord,
and peripheral nerves are applicable alike to sensory as well
as motor disorders when due to organic changes; hence,
when this fact is borne in mind, it will be unnecessary to
repeat what has already been given you.
In the treatment of anesthesia nothing can surpass in
its results the daily rise of the wire brush for about ten
minutes over the regions affected. This form of electrode
should be applied dry and with the secondary coil of a fara-
daic machine. The stabile electrode should be well moist-
ened and pressed closely in contact with some distant point.
If trophic disturbances co-exist with anaesthesia, I have
found the "combined current" (galvano-faradaic) to be
more efficacious than faradism alone.
Static sparks and static insulation often act wonderfully
in functional nervous diseases.
Static insulation has been previously described. It
should be administered daily for from ten to thirty min-
utes.
If the " indirect spark" is employed (see Fig. 30), the
length of the spark should be sufficient to be perceptible to
the patient, and the duration of the application should sel-
dom exceed five minutes. It is well to administer a fusil-
lade of sparks to the region of the spine after each insula-
tion, in case the sensory disturbances are dependent upon
hysteria or neurasthenia.
I seldom employ the " direct spark " (Fig. 3) except in
the treatment of organic disturbances of sensation or mo-
tion.* This form of administration should be used with
* Since these lectures were delivered I have at last perfected an im-
provement upon the Holtz static machine, upon which I have been
working for some time, and I have had one of this pattern built for my
own use by Waite & Bartlett, of New York. I intend soon to present
this improvement formally to the profession with appropriate cuts and
a description of the various modifications made. My own machine after
this model gave me a ten-inch spark during a " muggy " day in July,
when most static machines would produce but a feeble spark. It is
the most effective instrument of the kind which I have yet seen. It
consists of nine twenty-four-inch glass plates, six of which revolve. All
the joints of the case are hermetically sealed with soft rubber.
extreme caution if the generating machine is a powerful
one.
The "umbrella" electrode furnishes an agreeable and
effective method of concentrating static electricity to the
head of the patient. The- sensation is one which resembles
that of a strong breeze circulating through the hair.
Hemianesthesia (whether of cerebral or spinal origin)
is often benefited by cutaneous faradization of limited por-
tions of the area affected — a point first observed by Vul-
pian, who employed this method with marked success.
Trophic disorders may occasionally manifest them-
selves, often in the skin, nails, hair, and muscles, when sen-
sation is markedly affected. One such case (suffering from
locomotor ataxia) was lately placed under my care. The fin-
gers of both sides were almost destitute of sensibility to
pain, and tactile sensation was impaired. The nails were
thickened, loosened for half of their length, and deeply
pigmented (as if stained with iodine). The terminal pha-
langes were " clubbed," the nails being bent almost into a
semicircle. The skin was thickened and very hard under
the loosened nails. The "combined current" (galvano-
faradaic) with a wire-brush electrode caused decided im-
provement within a few weeks.
Neuralgia (when of idiopathic origin) is more success-
fully treated to-day by electricity than by any medicinal
agent. In many instauces it is cured in a few sittings.
It is well to bear in mind, however, the fact that neural-
gic pains are very often symptomatic of causes more or less
remote from the affected nerve, and that a permanent cure
is impossible in many instances as long as that cause actively
exists. Defective teeth, morbid processes in the bones,
pressure upon a nerve, organic changes in the nerve itself,
toxic diatheses, rheumatism, gout, reflex irritation from the
eye, uterus, digestive tract, ovaries, etc., cardiac and pul-
monary disorders, and many other morbid conditions, may
be enumerated as among the exciting causes of neuralgia.
Respecting the electrical treatment of neuralgic pains
(per se) the following deductions may prove of some advan-
tage to you :
1. If points of tenderness to pressure (puncta dolorosa)
exist along the course of the affected nerve or its branches,
it is well to subject them to stabile galvanic applications of
the anode, the cathode being placed at a neutral point.
2. The anode should be made to cover as large an area
as possible.
3. The duration of the sitting should not exceed five
minutes, save in exceptional cases. The sittings may be
repeated several times a day if necessary.
4. As a rule, it is unwise to break the current. In ob-
stinate cases the current may occasionally be reversed, with-
out changing the poles, by means of the commutator.
5. Faradization of the nerve and the use of the wire
brush upon the skin have been recommended when galvan-
ism proves unsuccessful in arresting the pain. It should
not be used (in my opinion) until galvanism has been thor-
oughly applied.
6. It is well in obstinate cases to direct the applications
of galvanism to the central origin of the affected nerve, as
well as to its peripheral distribution.
284
DELAY AN: ERYSIPELAS OF TEE LARYNX AND PHARYNX. [N. Y. Med. Jon*.,
7. Static electricity often produces marvelous results in
neuralgia. I have more faith in it as a cure for sciatica
than in any other remedial agent. It should be applied (by
the " spark " method) over the affected nerve. One sitting
has, in my experience, frequently arrested severe pain. It
gives immediate relief, in most cases, to muscular rheuma-
tism also, and to lumbago. Sufferers from muscular and
neuralgic pains are perhaps as frequently encountered by
the physician as any class, and static electricity should
highly recommend itself to your confidence for such cases.
The expenses of the outfit, and the fact that the machine is
too large for transportation, will probably prevent its gen-
eral use by the profession ; but, until its effects upon a
patient have been tried, I would caution you against ex-
pressing an unfavorable opinion, even if galvanism, fara-
dism, and medicinal treatment have proved powerless to
relieve the suffering.
8. The operation of electro-puncture of a nerve for the
relief of neuralgia has proved of benefit in the hands of
some neurologists; but it is an operation which, if injudi-
ciously employed, will produce electrolysis, and serious re-
sults may follow its use.
9. The electrical treatment of various other forms of
pain is similar to that of neuralgia. The judgment of the
physician should be exercised regarding the position and
size of the electrodes, the variety, strength, and duration of
the current employed, and various other minor points sug-
gested by the condition of the subject.
10. Visceral neuralgias (as, for example, the conditions
known as hemicrania, migraine, gastralgia, enteralgia, hepa-
talgia, etc.) are often relieved by electricity, irrespective of
the reflex or constitutional condition which induces the
morbid state. The removal of the exciting cause, however,
will greatly assist in making the cure a radical one. I have
long taught in my lectures that I had yet to encounter a
patient who had suffered for years from migraine who had
not some defect in the eye or its muscles as an exciting
cause. Experience leads me still to strongly assert this as
my conviction. The same cause is very frequently mani-
fested by paroxysms of spinal pain — peculiarly so at two
points, viz., between the scapula?, and at the junction of the
last lumbar vertebrae with the sacrum.
The currents which act best upon these cases are the
galvanic and static. I have in two instances employed
faradism in gastralgia with good results, but I regard it as
inferior to galvanism or franklinism.
In treating the abdominal viscera by galvanic currents,
one rheophore may often be attached with advantage to a
rectal electrode, and the other to a large electrode placed
over the organ to be influenced. I do not believe that
polar effects are to be particularly aimed at. In some cases,
an occasional substitution of the "combined current" (gal-
vano-faradaic) for galvanism makes the improvement of the
patient more rapid.
Static applications to the abdomen are best made by
employing indirect sparks of about two inches in length.
Long sparks are not borne well by sensitive subjects. If
patients are subjected to static insulation alone for twenty
minutes daily, or to the electric spray over the abdomen,
relief is often afforded and the application is painless. The
clothing need not be removed in making applications of
franklinism by either of these methods — a point which
renders the treatment particularly agreeable to ladies.
{To be concluded.)
Original Communications.
ERYSIPELAS OF THE
LARYNX AND PHARYNX*
By D. BRYSON DELAVAN, M. D.
Since the remarkable and exhaustive thesis of Cornil,
which appeared in the " Archives generates de medecine " in
1862, little new knowledge has been advanced, either in
the pathology, the clinical features, or the treatment of this
affection. Morell Mackenzie, in his excellent resume of the
subject, tells us that erysipelas of the mucous membrane
of the pharynx and larynx is, pathologically, similar to the
same malady when situated on the skin, and that it occurs
either primarily or by extension from the face along the
mucous tracts of the mouth, nose, or ear. Its causes are
the same as those which give rise to it when situated upon
the external parts of the body, although it has been most
often observed in the course of general epidemics of the
disease. Of eighteen patients seen, in whom the pharynx
was affected, fifteen were under the age of thirty, and two
thirds were females. Again, on inspecting the pharynx, the
appearance of the mucous membrane when affected with
erysipelas differs considerably according to the form of the
disease which is present ; the local phenomena are generally
very different from those of tonsillitis, but often can not be
distinguished from those of simple inflammation of the
part. Cornil makes three divisions of the malady, viz. :
(1) erysipelas with simple redness; (2) erysipelas with phlyc-
tsenulae ; and (3) erysipelas terminating in gangrene. Ery-
sipelas most commonly reaches the larynx from the pharynx,
but the former organ may be primarily affected while the
pharynx remains healthy. According to one author, quoted
by Mackenzie, the disease may extend still farther down the
respiratory tract. In cases which come under the first di-
vision the diagnosis must remain doubtful except in cases
where the throat lesion is accompanied by manifestations
upon the skin.
As to the prognosis, the dictum of Hippocrates — name-
ly, " When erysipelas extends from within outward it is
a favorable symptom, but when it removes to the internal
surfaces it is a deadly one" — has been confirmed by modern
observation. In nine oases analyzed by Cornil where the
face was first attacked, seven deaths occurred ; whereas, in
nine other instances where the enanthem preceded the skin
eruption, seven recoveries took place. Mackenzie states that
he has seen but four cases in the whole course of his prac-
tice.
* Read before the American Laryngological Association, June 24,
1885.
Sept. 12, 1885.]
DELAY AN: ERYSIPELAS OF
THE LARYNX AND PHARYNX.
285
From the foregoing statements it would appear that the
disease in question has been so long ago recognized, and its
nature is so well understood, as to render its introduction
at the present time unnecessary. In searching for the rec-
ords of authentic cases in available American literature,
however, we are surprised to find but a single instance in
which the disease has been described, namely, the case re-
ported last year by Dr. T. A. De Blois. The case reported
by Dr. "William Porter, of St. Louis, was that of an Eng-
lishwoman whom Dr. Porter attended while residing in
London. Whether it is more rare in this country than in
Europe, or whether, on the other hand, it is either allowed
to pass unrecognized or else regarded as a simple and ordi-
nary complication of the general affection unworthy of spe-
cial mention, it is impossible to say. That the condition is
an important one no one will question, while the very gen-
eral nature of the treatment suggested proves that additional
light upon the subject is greatly to be desired. With the
intention of awakening a sufficient interest in it to secure a
more general- recording of such cases as may arise, the fol-
lowing histories are presented :
Edward Smith, aged twenty-nine, of robust appearance, had
always enjoyed good health. On February 10, 1883, two
months after admission to the workhouse, applied at the dis-
pensary, complaining of chilliness, general muscular soreness,
and pain in the bones. There was slight soreness of the throat,
and pain in deglutition, which he stated he had first felt upon
the right side. The tonsils were congested and slightly en-
larged, particularly the right.
February 11th, 12th. — Felt much worse and experienced
more dysphagia. He also complained of a feeling of dryness in
the nasal passages and inability to breathe through the nose.
Described the nasal condition as being like a " cold in the head."
The pulse was somewhat accelerated, and there was a slight rise
of temperature.
14th. — Was transferred to the hospital, all of the above
symptoms being exaggerated. Temperature 102°, pulse 96,
respirations 27. Tongue and teeth covered with sordes ; ton-
sils and pharynx deeply congested. At this time also a her-
petic eruption appeared on the face, below and to the outer side
of the angle of the mouth.
15th. — On the morning of this day an erysipelatous redness,
attended with swelling, appeared upon the upper lip, adjoining
the alas of the nose, and fading off upon the cheeks. There
was also severe pain in the back of the head and the neck. The
appetite was good, and there was little malaise. The tempera-
ture, however, was 104°, pulse 96, respirations 24.
17th. — The swelling and redness had extended to the margin
of the hair, and had invaded the neck. The face was covered
with blisters. The pulse was running and intermittent at 80,
and the tongue black and dry. Severe pain still continued in
the back of the neck.
18th. — Did not appear to suffer much pain. Erysipelas not
extending.
19th. — Patient fell into a semi-conscions condition, from
which it was impossible to arouse him, and questions put to
him met with no response.
21st. — Semi-consciousness continued, but the patient began
to be very restless and delirious. His hands were kept in con-
stant motion, and it was almost impossible to keep him in bed.
The facial swelling had subsided, and exfoliation of the epi-
dermis had begun. The tongue was still black and thickly
coated. The pulse and temperature were normal.
22d. — Patient was more rational and able to answer ques-
tions.
28d. — "Was again slightly delirious, constantly sitting up in
bed and throwing off the bedclothes, and fighting aoy one who
came near him. Temperature 97°, pulse 50, respirations 21.
24th. — The delirium became active and of an hilarious char-
acter, the patient singing, shouting, and constantly arranging
the bedclothes, and imitating the actions of the ward attend-
ants. The condition of the tongue had cleared somewhat, and
the appetite had returned.
26th. — Patient was slightly irrational. Tongue clean; exfo-
liation of epidermis of face, neck, and ears progressing. Tem-
perature and pulse normal.
March 3d. — Delirium entirely gone. Exfoliation almost com-
plete. Hair began to fall out. During the whole illness there
was obstinate constipation.
12th. — Patient was discharged, apparently cured.
On the morning of March 16th, however, the attention of
the house surgeon was called to Smith cm account of his wild
appearance and strange actions. He was wandering aimlessly
about the corridors, and seemed sullen and morose. This con-
tinued until the morning of the 18th, when he was transferred
to the hospital again. He would pay no attention to those
about him, answered questions a long while after they were
put to him, imagined that his fellow-workmen were trying to
annoy him, and that every one was plotting against him. While
in the hospital he had delusions of a religious character at times,
and at other times he imagined that some one whom he did
not know was constantly urging him to the performance of a
variety of strange actions, and he believed that he must obey.
He was treacherous, and would strike at the attendant when-
ever a good opportunity presented. His nights were restless
and sleepless, and the constant hallucination of an outside im-
pelling influence kept him busily engaged, while he would hide
under the bed, tix himself in various positions in bed, arrange
the bedclothes, and at times sit and stare at some one object for
half an hour. If given something to do, he did it well, and
while busy was happier and more satisfied to stay in the ward,
but, when unemployed during the day, would constantly walk
up and down, watching an opportunity to escape. During the
five days he remained in the hospital he had no rise of tempera-
ture, his pulse was somewhat accelerated and weak, and his ap-
petite good. As soon as his transfer could be effected, he was
sent to the Insane Asylum at Ward's Island, where, when last
heard from, he still remained.
The following case occurred in the wards of the New York
Almshouse Hospital during the service of the writer in the
spring of 1882. Unfortunately, careful notes were not taken at
the time, and it will, therefore, be possible to report only as
much as can be given from memory. The patient was an aged
pauper of about seventy years, large, somewhat stout, and de-
cidedly rheumatic. She was attacked with what at first seemed
an acute laryngitis. The disease, however, spread rapidly in
both directions, involving both the lungs and the pharynx, pro-
ducing in the former distinct and widespread broncho-pneu-
monia, and in the latter an intense congestion. The mucous
membrane here was also cedematous, and of a dark, purplish
color. So peculiar was its appearance, and so threatening the
extent of the oedema, that a laryngoscopic examination was made
to ascertain the probable necessity for tracheotomy. Although
in a state of general tumefaction and of the same dark color as
the pharynx, there was an ample rima glottidis, but marked
hoarseness of the voice. The constitutional symptoms were
slight, considering the nature and severity of the attack. By
degrees the inflammation extended from the pharynx to the
lips, whence, apparently having received a fresh impetus, it
286
DELAY AN: ERYSIPELAS OF THE LARYNX AND PHARYNX. [N. Y. Mkd. Jot*.,
spread over the face. Meanwhile, the co-existence of diarrhoea,
mild delirium, and continued high temperature rendered the
general condition grave. This period marked the height of the
attack. The lungs were first to improve, and the disappearance
of the pneumonia was followed hy a subsidence of the laryngeal
and pharyngeal inflammation and a marked improvement in
general. Strange to say, as desquamation occurred in the face
and neck, the erysipelas extended, by slow degrees, over the
whole body, the march being slow, the general symptoms mild,
and no great extent of surface being involved at any one time.
At the end of several weeks this process was completed by in-
volvement and subsequent desquamation of the legs and feet-
The patient recovered.
The case first related would, if classified according to
the method of Cornil, belong to division number two, since
it was decidedly severe in its nature, and the presence of
phlyctamulae, although not mentioned in the history by my
house surgeon, was distinctly ohserved by myself. The
features of the case which especially distinguish it are, first,
the occurrence of the disease idiopathically in a patient
who, so far as could be learned, had not been exposed to
any erysipelatous infection ; secondly, the distinct limita-
tion' of the disease to the tonsil for a period of three days ;
and, thirdly, the marked cerebral disturbance and subse-
quent insanity.
No especial cause of irritation was apparent in the ton-
sil ; the man had been to all appearances unusually strong
and healthy, and the sanitary condition of the premises was
at the time tolerably good. The limitation of the inflamma-
tion and its absolutely benign appearance at the beginning
of the attack were sufficient to disarm suspicion as to its
true nature, and entirely out of harmony with the subse-
quent severity of the symptoms. By far the gravest of
these was the effect of the disease upon the brain. So far
as could be ascertained, the patient had never before mani-
fested any sign of mental aberration. His insanity, there-
fore, bore such a distinct relation to the attack that, be-
yond question, the one was intimately associated with the
other. Of course, it is by no means unusual for facial ery-
sipelas of the ordinary type to be complicated with delirium
and coma, and even the more serious cerebral symptoms
indicating meningitis, so that it is not surprising to find it
developed by the form under special consideration. The
mechanism of this metastasis, however, is a matter of as
much interest as it is of uncertainty. Formerly it was ex-
plained as being a localized manifestation of a general morbid
condition. At present believers in the germ theory will
probably maintain that it is due to an incursion of the bacil-
lus of erysipelas from the frontier regions to the interior.
Before accepting the foregoing it seems but just to call
attention to the possibility of direct extension of the disease
from the deeper layers of the olfactory region, and through
the cribriform plate of the ethmoid bone, to the meninges.
Improbable as this may appear, it is still worthy of notice,
since the influence of inflammatory conditions of the mid-
dle ear and of the frontal sinus in exciting cerebral com-
plications is well attested. By whatever process it may
have occurred in the case under consideration, there was
established, without doubt, a meningitis, at first acute.
Subsequently the acute attack passed into the chronic form,
presenting the symptoms of this condition typically de-
scribed toward the end of the history.
Case number 2 is more after the usual course of the
disease. The patient was old, feeble, and lithiatic. She
was housed in a crowded, ill-ventilated hospital ward, in
which, although there may not actually have been another
case at the time, erysipelas was never, for any great length
of time, absent.
In an article published in the " Rivista Cliuica e Tera-
peutica," No. 1, 1885, Dr. F. Massei, of Naples, endeavors
to prove, from a study of thirteen cases, that the so-called
primary oedema of the larynx, or phlegmonous laryngitis,
corresponds clinically to a localization of erysipelas in the
larynx. He describes the objective symptom of the disease
as being a marked swelling, which, beginning at the epi-
glottis, extends to the mucous membrane of the arytamo-
epiglottic ligament and the inter-arytamoid space, causing
dyspnoea, dysphagia, and aphonia. The onset is generally
sudden, and the laryngoscope shows such intense swelling
that the interior of the larynx can not be demonstrated.
Blood and pus are occasionally poured forth from spontane-
ous rupture of the mucous membrane. Often the swelling
migrates, decreasing on one side and increasing on the
other. The prognosis is, either recovery or else death by
asphyxia or pneumonia.
Massei considers the disease erysipelatous for the fol-
lowing reasons :
1. Its rapid development and its tendency to wander,
as well as its predilection for parts in which the lymphatics
are abundant.
2. The constitutional symptoms which resemble those
of erysipelas.
3. Its want of resemblance, from its migratory character,
to the ordinary forms of laryngitis.
4. The tendency of the disease to extend to the lungs,
and, finally, its occurrence during the course of epidemics
of erysipelas.
He concludes :
1. There is a primary erysipelas of the larynx.
2. Many cases reported as primary oedema of the larynx
are really cases of erysipelas ; this occurs more commonly
than is generally supposed.
3. There are two forms: in the first the local manifes-
tations precede the general ; in the second they close the
scene.
4. The best methods of treatment are applications of
cold, scarification, and, finally, if asphyxia threatens, trache-
otomy.
It will be seen that Massei's observations relate solely"
to the larynx. Although somewhat general in their nature,
they are given as supplementing the views of the writers
quoted above, while the recommendations as to treatment
still leave much to be desired.
The writer is certain that, as house surgeon ten years
ago in a large public hospital iu which the erysipelas pa-
vilions formed an important part of the service, both laryn-
geal and pharyngeal cases were occasionally presented.
Unfortunately, their real nature was not then recognized*
and in the lapse of time which has since occurred the recol
Sept. 12, 1885.]
MACKENZIE: INFLAMMATION OF TEE AIR-PASSAGES.
287
lection of the facts connected with them has become too
indistinct to enable him to refer to them with any confi-
dence or accuracy.
DISCUSSION.
Dr. De Blois said : My case, to which the reader has just
referred, closely simulated follicular tonsillitis, and I treated it
as such for twenty-four hours. The pharynx was involved in
the inflammatory process, and both tonsils were equally affected.
On the next day it appeared to have extended to the nasal cavi-
ties. There was a discharge from the nose, and what was much
like a diphtheritic membrane in the posterior nasal cavities.
There was no appearance on the face of any skin affection.
There was some malaise, but the patient did not have a higher
temperature than would be usual in the course of a severe tonsil-
litis. On the fourth day, when the disease passed on to the nasal
cavities, the inflammation of the tonsils was somewhat im-
proved. Later erysipelatous redness appeared over the bridge
of the nose. The internal manifestations meanwhile became
somewhat better, and the case progressed to a very severe at-
tack of facial erysipelas. She subsequently recovered. The
point which I wished to bring out was, the difficulty of diag-
nosis.
Dr. Rice. — It would seem strange that erysipelas of the
larynx and pharynx should be such an infrequent disease when
the conditions are so favorable to its development. Cases of
facial erysipelas are very common when at the same time the
patient is suffering with extensive ulcerations of the nose and
pharynx, which, we should suppose, would invite an extension
of the disease to this locality. And yet this is a rare occur-
rence. Ulcerations on the cutaneous surface are almost always
attacked ; on the mucous membrane it is the exception. I am
convinced that erysipelas of the larynx does exist where a diag-
i nosis is not made. I remember in the erysipelas wards of Char-
| ity Hospital there were two cases (which were called "oedema
glottidis ") where tracheotomy was done ; the inflammation
here was probably of an erysipelatous nature.
Dr. Roe. — An interesting case of erysipelas of the larynx
and pharynx came under my observation about a year and a
half ago, in a lady, about thirty-seven years of age, of a nervous
sanguine temperament. She was under treatment for naso-
pharyngeal catarrh. The attack seemed to be due to exposure
during a slight fail of snow, in the course of which she rubbed
her face with snow. Within six hours afterward she had well-
marked facial erysipelas. This went on its usual course, but
soon assumed a severe type. Within thirty-six hours afterward
she had delirium. The erysipelas extended to the neck and into
the pharynx, also into the larynx, causing marked oedema of the
larynx and pharynx, so that there was severe dyspnoea for about
twenty-four hours. One night I remained in the house expect-
ing to have to perform tracheotomy before morning. I used
the usual course for erysipelas — i. e., mild alkaline sprays, with
a little alcohol — which seemed to have a very quieting and sooth-
ing effect, and soon the erysipelas began to subside in the face
and gradually in the larynx and pharynx. In about four days
the symptoms in that region disappeared. These cases must be
unusual, as Dr. Delavan has said, although often attributed,
probably, to other causes.
Dr. Cohen. — Having seen the admirable effects of the hypo-
dermic injection of hydrochlorate of pilocarpine in facial ery-
sipelas in hospital practice, it occurs to me that it would be
an admirable method of treating these rare cases. Its action in
doses of one sixth of a grain is very prompt.
Dr. Delavan, in closing the discussion, said: There seems to
be no reason why any inflammatory condition of the pharynx —
such as diphtheria, follicular tonsillitis, or peritonsillar abscess —
should not excite an attack of erysipelas, so that a case begin-
ning as a simple attack of one of the former affections may re-
sult in the latter. With regard to the use of pilocarpine, I have
found the dose recommended to be, in some cases, excessive,
and would urge the employment of this potent drug in smaller
quantities, one twentieth of a grain often being sufficient.
REFLECTIONS ON THE AETIOLOGY OF THE
SIMPLE INFLAMMATOBY AFFECTIONS
OF THE UPPER AIR-PASSAGES*
By JOHN N. MACKENZIE, M. D.,
BALTIMORE.
" llle bene curet, qui bene morborum causas agnoscil." — Celsus.
In view of all that has been said and written concern-
ing inflammatory conditions of the naso-laryngeal tract, it
is amazing to find what little advance has been made toward
a more rational conception of the causes that underlie dis-
eases of such prevalence and wide distribution.
It is not the purpose of the present communication to
treat in an exhaustive manner the conditions under which
inflammation of the upper air-passages develops, but simply
to offer for your consideration a few general observations
and desultory reflections, which, I trust, through the discus-
sion which follows them, may serve to throw new light
upon the subject, and stimulate others to more perfect and
fruitful research.
At the outset of our inquiry we should divest the mind
of the idea that the pathology of nasal and laryngeal disease
is an isolated pathology. The eruption of catarrhal processes
in the respiratory tract is governed by the immutable laws
that condition the development and course of inflammation
in general, and the rational interpretation of nasal and
laryngeal affections presupposes, therefore, the application of
general pathological principles to the peculiar conditions
which the anatomical and physiological functions of the
structures involve. Above all, we should remember that
peculiarity of structure is not anatomical isolation ; we
should remember the correlation of organ and organ, the
sympathy of tissue and tissue which make up the perfect
physiological life of man. In looking upon the subject
from the high vantage ground of general pathology and
laws of health, we may, therefore, more readily apprehend
the role which external and internal influences play in the
evolution of nasal and laryngeal disease than if we viewed
the same from the level of a narrow specialism or from the
standpoint of the mere empiric.
I. Inflammation of the upper respiratory tract, either in
its entirety or localized in its individual parts, is a disease
of the human race which has existed from the remotest
period of historic time.
II. As the chief predisposing and exciting causes of the
affection have been in operation for all ages, it follows,
therefore, that its origin is coeval with the birth of man.
III. The evolution of nasal, pharyngeal, and laryngeal
inflammation in a given locality is, in all probability, a part
* Read before the American Lar)-iigological Association, June 24,
1885.
288
MACKENZIE: INFLAMMATION OF THE AIR-PASSAGES. \S. Y. Med. Joob.,
of its geological history, and goes on pari passu with its
varying meteorological conditions. Hence the geographical
limits of the disease have varied with the different epochs
of the earth's formation.
The elaboration of the above propositions involves an
inquiry into the origin, the predisposing and exciting
causes of nasal, naso-pharyngeal, and laryngeal inflammatory
affections, and their distribution over the surface of the
earth.
Origin. — In the third book of Plato's " Republic " the
philosopher tells us that the names of catarrhs were un-
known to Homer, and only came into use in the age of
Socrates. This assertion of the Grecian sage has been made
the groundwork of the thesis that catarrhal diseases are the
products of civilized life, and furnishes, among other things,
the basis of the Schneiderian argument that these affections
are born of luxury and ease and of the general degeneracy
of mankind.
It is doubtless true that a marked tendency to catarrhal
diseases belongs to modern man from the accidents wbich
pertain to his environment, and that as civilization awakens
morbid conditions unknown or rarely met with in the savage
state, so the disposition to inflammatory troubles of the
upper respiratory passages may be encouraged by transmit-
ted vices and the enervating surroundings of modern social
life. At the same time it is reasonable to assume that, as
the chief causes productive of acute and chronic inflamma-
tion of the naso-laryngeal tract have been in operation from
the remotest times, the origin of the affection is therefore
traceable to that of man himself.
The very etymological derivation of tbe word coryza
carries us back through the dialects of the Hebrews, Ara-
bians, Chaldeans, and Assyrians to the time when history
emerges from fable ; the attention paid by the most ancient
exponents of medical art, of which we have any record, to
inflammatorv states of the nose and throat, implies the
former frequency of these affections, while the derivation of
the terms angina and cynanche, and the early origin of
broncliotomy, point to their recognition of the most danger-
ous forms of laryngeal disease. The classification and cor-
rect clinical history of disease is, moreover, a process of
gradual evolution, and, in view of the confusion which
reigned among the latter - day nosologists in regard to
laryngeal affections, it is not surprising that in the most
ancient records of medicine we fail to find that exact ana-
tomical division of catarrhal affections which was the natu-
ral outcome of subsequent more advanced anatomical and
physiological investigation.*
Inflammatory disorders of the upper respiratory appara-
tus may be the result of a host of conditions external to
the body which arise from man's relation to the outer world,
may proceed from agencies within the organism, whose
sphere of operation embraces the system as a whole, or is
limited to its individual parts, or, finally, they may be the
outcome of defective anatomical and physiological relations
* Hence we find in the Ayur Veda affections of the larynx con-
founded with those of the palate and pharynx, and among certain of
the Hippocratic and Galenic schools the names pharynx and larynx are
occasionally employed as convertible terms.
— of absence or abrogation of activity in the respiratory
structures themselves and in the functions and forces under
their control.
The discussion of the causes proceeding from the first
source leads naturally to the consideration of the geographi-
cal distribution of the affection.
Geographical Distribution. — Predisposing and Excit-
ing Causes. — The geographical limits of nasal and post-nasal
catarrhs are as yet imperfectly defined, but it is highly
probable that they bear a close relationship to the distribu-
tion of catarrhal affections of the respiratory organs in gen-
eral over tbe surface of the earth. Thus it may be laid
down as a rule that catarrhal inflammation of the nasal pas-
sages is much more frequently met with in cold- than in
warm countries, in high than in low latitudes. The obser-
vations of travelers and explorers show that the nearer we
approach the equator the less prevalent become affections
of the respiratory apparatus, while in the temperate zone
they are the most common of all diseases, and preponderate
in these regions according to the proximity of the individual
localities to the polar circle. In the temperate zones of
both hemispheres catarrhs are more frequently met with in
those places which lie between the isothermal lines of 18°
and 4° (Seitz). The prevalence of these affections is related
not only to the geographical position of a given country,
but also to its elevation above the surface of the sea ; the
higher above the sea-level, the more marked the tendency
to catarrh (Hirsch, Seitz), a fact partially explicable by the
analogy of natural conditions or meteorological relations
between high mountainous regions and those of the frigid
zones. In every zone the geographical distribution of the
complaint depends, other things being equal, apparently
mainly on climatic influences. In those countries where
extremes of temperature follow each other in rapid succession,
where the thermo- and barometrical fluctuations are most
sudden and occur with the greatest frequency, and where the
material composition of the atmosphere is continually chang-
ing, catarrhal affections of the naso-laryngeal tract are most
frequently met with. The appearance of the disease seems to
depend not so much upon the degree of heat or cold as upon
the rapidity and intensity of the change from the one to the
other. In warm countries, coryza and allied affections most
frequently prevail during the sudden cooling of the atmos-
phere by rain-showers, electrical disturbances, or when the
heated condition of the atmosphere alternates with damp-
ness and chilliness of the nights. In a similar manner
the more or less sudden passage from a dense to a rarefied
atmosphere, as in balloon and mountain ascensions, favors
the development of nasal congestion and inflammation.
The influence of season in the production of nasal inflam-
mation is simply a part of the greater question of tempera-
ture mutations, and will therefore vary with the period of
greatest temperature changes in a given year. While spring
and autumn furnish perhaps the largest percentage of nasal
and laryngeal catarrhs, the coryza which appears in the
summer months, when the air is suddenly cooled or altered
by electrical and other disturbances, yields to none in the
severity of its symptoms and course.
Of all conditions of the atmosphere the most pernicious
Sept. 12, 1885.J
MACKENZIE: INFLAMMATION OF THE AIR-PASSAGES.
289
to the nasal, and consequently to the pharyngo-laryngeal
mucous membrane, is perhaps its saturation with aqueous
vapor. Its influence is much more potent in the production
of nasal inflammation than that of cold. Indeed, the in-
jurious effect of the latter, per se, has been grossly over-
rated, and, if we examine the subject closely, we will find
, that there are many other agencies at work whose opera-
i tion explains the prevalence of these affections in the frigid
I zones and in the regions of perpetual snow. The effect of
moisture is furthermore intensified by its association with
intense cold or oppressive heat.
It is impossible to overlook the role of the winds, espe-
i cially when associated with brusque thermometric changes,
in the spread of coryza and allied affections. The strata of
air of different temperatures which they bring with them,
the moisture, dust (germs ?), and, in some instances, the
physical shock and pressure which they exert upon the
body, as well as the rapidity of evaporation of the cutane-
ous and respiratory transpiration which they occasion, are
powerful agents in the determination of naso-laryngeal
catarrh. The terrible effect of the hot wind of the desert up-
on the throat and nose leads the camel instinctively to bury
its nose in the sand until the fury of the tempest is past.
Besides the meteorological relations which condition
the geographical distribution of these affections, there are
others which pertain to the geological character of the soil,
I to the configuration of the locality, and to the emanations
which arise from the surface of the earth. The two former
furnish additional proof in favor of the power of climatic
; conditions in the evolution of naso-pharyngeal inflamma-
i tion. It is not within the scope of the present paper to
enter into an elaborate discussion of this vast and imperfect-
ly understood question, but it may be said, in general, that
the temperature of a given locality will depend, to a certain
extent, upon the color of the soil and the presence or ab-
sence of vegetation. In some countries — as, for example, in
Savoy— the peasants spread dark earth upon the land which
I they desire to cultivate early, which causes the snow to
melt fifteen to twenty days earlier than in other localities
(Tortual) ; it is a well-known fact that the temperature is
lowered and humidity of the soil encouraged by the pres-
ence of forests or large tracts of dense undergrowth. The
i presence of vegetation exerts, too, a remarkable influence
upon the chemical composition of the air, and hence upon
the development or dissipation of nasal and other forms of
catarrh. The noxious exhalations from certain forms of
vegetable life probably act as indirect or predisposing agen-
l cies in the spread of catarrhal disease, while the presence
of others, by purifying and tempering the atmosphere or
filling it with certain odors, seems to secure immunity from
the affection. The sulphurous air of volcanic regions has
been utilized from time immemorial in the treatment of
laryngeal affections, and the singular infrequency with
': which the latter are encountered in places where the air is
I laden with resinous and balsamic odors has been familiar
from the earliest times. The configuration of a country
enters as a factor in the localization of catarrh in so far as
I it conduces to exposure to the variations in temperature
which have been mentioned above.
There are also a vast number of injurious influences de-
pendent upon modes of life, dress, imperfect sanitary con-
ditions, etc., which have been brought forward as the
alleged causes of localization of catarrhal affections of the
respiratory tract, which, although exercising an undoubted
irritating effect, are nevertheless purely secondary and acci-
dental, and have led to crude hypothesis and hasty gener-
alization concerning the essential causes of these diseases.
There are a multitude of conditions which follow as the
natural results of imperfect sanitation and professional occu-
pation which act as predisposing and often exciting causes
of nasal inflammation. In general, it may be said that
residence or work in a confined or overheated atmosphere,
or in one filled with impure gases or floating particles of
organic or metallic matter, conduces to the development of
the disease. Thus it is well known that artisans who are
subjected to a dusty atmosphere — tobacconists, workers in
woolen goods, stone-cutters, millers, laborers in chemical
works, etc., or in overheated apartments, as, for example,
bakers — are thereby rendered more susceptible to catarrhal
affections. In addition to the meteorological conditions
which prevail in elevated regions, as, for example, the Alps,
the finely divided particles of metallic dust suspended in the
atmosphere are said to be important factors in determining
affections of the respiratory apparatus. The nasal erectile
bodies are peculiarly sensitive to the impression produced
by certain noxious gases, especially those given off in the
combustion of coal, while the furnace heat of the modern
dwelling, and the dry, impure air of apartments fed by the
majority of coal-burning stoves, and the varying tempera-
tures of the different rooms, create a vulnerabilitv of the
mucous membrane which, in our American cities, consti-
tutes a not unimportant a)tiological factor.
In some parts of our country there is a widespread
popular belief that dust is the chief factor in the localization
of inflammatory disease in the naso-pharynx. As there are
some who ascribe all diseases to the peripatetic excursions
of a vagrant micrococcus, so there are others who see in
dust the source of all our ills. While it is undoubtedly true
that dust, when accidentally lodged in the naso-pharynx,
may give rise to inflammation, I believe that comparatively
few cases originate in that way. In some of the Western
States the prevalence of large quantities of dust in the at-
mosphere is supposed to determine the geographical distri-
bution of the complaint; but even here, in estimating the
amount of injury done by dust in this case, we should not
forget the important meteorological changes that condition
its presence in the atmosphere, nor should we lose sight of
the fact that these localities are thousands of feet above the
water-level, a condition that subjects them more easily to
impressions made by sudden variations in the temperature
and brings them directly under the dominion of the winds
that sweep across the continent from sea to sea. Moreover
when an individual is exposed to an atmosphere tilled with
dust, the greater portion of the inhaled particles is retained
within the nostrils. This is due in a great measure, as 1
have pointed out elsewhere, to the erection of the turbinated
corpora cavernosa, which latter serve, in that respect, a cer-
tain teleological purpose. That portion which finds its
290
JAR VIS: NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS. [N. Y. Med. J
way into the posterior nares is carried into the lower (not
the upper) pharynx, not only by the force of the inspiratory
stream but also in obedience to the law of gravitation.
When the atmosphere is unusually dense, as in storms of
dust, this erection of the corpora cavernosa is often so con-
siderable as to necessitate mouth-breathing, and it is to a
large extent in this way that the lower pharynx and larynx
become filled with foreign matter. It is also a notorious
fact that in the nasal passages themselves the region of
olfaction is much less liable to catarrhal inflammation than
the respiratory passage. The nasal pharynx is therefore
infinitely less liable to inflammation from a dusty atmos-
phere than either the larynx or lower pharyngeal cavities.
Among the influences which, approaching from the exter-
nal world, encourage the eruption of naso-laryngeal affec-
tions, the chief, and at the same time predisposing, exciting
cause, and that which determines the geographical distribution
of nasal, naso-pharyngeal, and laryngeal catarrh, is that com-
bination of varying meteorological conditions which are under-
stood when speaking of a changeable climate ; the. home of
naso-laryngeal catarrh is the land of the greatest and most
rapid thermo- and barometrical change*
Turning now from the effect of temperature changes and
the direct action of local irritation from substances derived
from the external world to the agencies which, operating
within the organism, determine the localization of catarrhal
disease in the nasal passages and throat, we must confess
that the ancients exhibited the greatest shrewdness of ob-
servation when they referred these affections to defective
digestive processes and lowered powers of assimilation.
Catarrhal diseases, according to the fathers of medicine, are
due to imperfect " coction " — that is to say, imperfect
assimilation — and the resulting discharge or secretion was
looked upon as aliment which had not undergone the neces-
sary digestive changes, or, in other words, as half-cooked
food. While their notions of the aetiology of catarrhal
affections were in the main crude and curiously influenced
by the prevailing philosophical vagaries of their time, they
nevertheless contain an amount of common sense which it
behooves us to pause and consider.
It may be said, in general, that all those influences which
impair the general health, interfere with the proper circulation
or impair the constituents of the blood, retard the processes of
digestion and assimilation of food, or beget a hypersensitive
condition of the vaso-motor nervous system, react upon the
upper respiratory tract in common with the other organs of
the economy, and predispose, other things being equal, to
catarrhal inflammation of the same. Thus the latter is
more liable to develop in anaemic persons with weak, re-
laxed conditions of the tissues and who lead sedentary lives,
and in those of highly nervous organization, than in those
of strong and vigorous constitution and who pass most of
their time in active out-door exercise. The existence of
syphilis or tuberculosis in an individual is a constant invi-
tation to catarrhal inflammations of the nose and throat, and
•M ■ ■
* The alternate subjection of the pharynx and larynx to extremes
of heat and cold in the ingesta acts, though to a far less degree, in the
same manner in determining catarrhal inflammation as the sudden
changes in the temperature of the external air.
the same is true in regard to the rheumatic, gouty, scorbutic
diatheses, to chronic alcoholismus, and a host of other affec-
tions.
Over-indulgence of the appetites, excesses of all kinds,
habitual interference with the bodily excretions, notably
the intestinal, predispose to inflammatory disease of the
naso-laryngeal tract, so that Schneider was not far from the
truth when he said that the cure of catarrhs consisted in
"sobriety, continuous bodily exertion, and tranquillity of
mind."
(To be concluded.)
CATARRHAL AFFECTIONS OF THE
NASAL PASSAGES
AS A CAUSE OF
PULMONARY PHTHISIS,
WITH SPECIAL REFERENCE TO THE QUESTION OF
HEREDITY.
By WILLIAM CHAPMAN JAR VIS, M. D.
(Concluded from page 265.)
I will now direct your attention to the color of the mu-
cous membrane of the upper air-passages as an indication
of incipient or developed pulmonary phthisis. The color
I refer to is a peculiar anaemic, pink hue, resembling that
sometimes observed in hypertrophy of the tonsils. This
pallor is by no means confined to the atrophic form of
rhinitis, where, as far as the nostril is concerned, it invari-
ably occurs, but exactly opposite to what we might expect
is discoverable in rhinitis hypertrophica, where its presence
should naturally lead one to suspect and find the anaemia of
pulmonary phthisis. In two of the reported cases appended
to this paper the condition was found in connection with
a rhinitis hypertrophica ; and in another, likewise phthisic-
ally inclined, it was associated with an hypertrophic and
atrophic process in the same individual. I still favor the
view advanced by me several years since, in an article on
laryngeal phthisis,* that anaemia of the upper respiratory
mucous membranes influences the character of reparative
changes, as exhibited, for instance, in the conversion of
accidental abrasions in the larynx into phthisical ulcerations.
It would seem to indicate diminished vitality or a lowered
power of resistance. As an example, I might mention that
my experience in operations upon the septum leads me to
expect an exceedingly slow reparative process, and one
usually requiring assistance in patients presenting marked
anaemia of the septal mucous membrane.
In this class of cases, as we might naturally expect, the
slight vascularity of the mucous membrane favors the ac-
tion of the cocaine salts, and they are, in my experience,
the only ones in which we can positively promise freedom
from pain before operating.
I have selected a few histories from my case-book as
good illustrations of the aetiological relations of nasal ca-
tarrh to pulmonary phthisis.
Case I. — Mr. , engineer, aged thirty, came to me
for treatment in October, 1884. His complaint was a long-
* "Archives of Laryngology," vol. iv, p. 187.
Sept. 12, 1885.J JARVIS: NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS.
291
standing catarrh. The right nostril (Fig. 9) for respira-
tory purposes was practically useless, and had been so as
far back as he could remember. Nasal respiration was, and
had always been, carried on through the left nostril. De-
spite, however, the ease with which air was inspired through
the free nostril, he had never been comfortable, on account
of the respiratory obstruction referred to the narrow nostril,
and eagerly utilized the smallest amount of space afforded
at intervals by the temporary subsidence of the congested
turbinated tissues. In addition to the respiratory discom-
fort, he was annoyed by the accumulation of inspissated
mucus in the larger naris, and was wearied by the constant
though ineffectual efforts employed to remove the ropy
muco-purulent matter and offensive crusts. He was also
tormented with the usual throat and laryngeal symptoms
which occur as a result of the disturbances to nasal respira-
tion and drainage. The slightest exposure was likely to be
followed by obliteration of the insignificant respiratory aper-
ture in the right naris, producing a disagreeable sense of
tension in that nostril, evidently arising from the turbinated
turgescence. The same exposure sometimes resulted in
attacks of lung trouble, occasionally confining him to the
house. In appearance he was thin and anaemic, his emacia-
tion carrying with it more the impression of a peculiar build
than an unusual or rapid loss of flesh. His appetite, though
usually excellent, was capricious, and even at its best was
not followed by any noticeable increase in weight.
Examination. — An examination of the nares anteriorly
with my nasal speculum revealed the presence of just those
conditions which would serve to account for the symptoms
complained of. The vomer, ethmoid, and triangular carti-
lage projected to the right in the form of a general and easy
incline from above downward. Anteriorly, however, the
columna was displaced laterally to the right as an irregular
knuckle of cartilage (see Fig. 9). No evidence of disfig-
urement of the external naris could be observed on ordinary
inspection (another indication of the hereditary character
of the complaint). An interesting feature observed upon
the septum in the left nostril was a vertical elevation near
the ethmo-vomerine suture, caused by the abrupt interrup-
tion of the perpendicular plate of the septum at this point.
Behind this vertical ridge quantities of glairy or inspissated
mucus would collect, and, by reason of the excessive breadth
of the inner naris at this point, they would effectually elude
the action of the respiratory pressure exerted by the pa-
tient to remove them. The turbinated structures and peri-
turbinated mucous membrane was markedly atrophic in the
larger or left nostril, but the inferior turbinated tissue in the
right or narrow nostril was slightly hypertrophied. Just
here we note an instructive example of cause and effect, for,
as we might have expected, the life-long inspiration of air
through a single nostril — unable, through secretory disturb-
ances, to furnish the necessary amount of moisture — is natu-
rally followed by desiccation and atrophy of the pituitary
membrane. The right nostril, on the contrary, being almost
completely stenosed, is always bathed in the nasal fluids.
In other words, with certain modifications, it is a case of
unequal distribution of respiratory labor with the natural
consequence, a rhinitis atrophica and hypertrophica occur-
ring in the same individual. The pharynx, larynx, and
trachea presented the anaemia of phthisis. The patient's
lungs were carefully examined by Dr. W. H. Katzenbach,
of the Chest Department of Bellevue Hospital, and myself,
and our suspicion was confirmed by the detection of the
very early signs of pulmonary phthisis.
An interesting point in the patient's family history re-
lated to his brother, a physician, who, several years since,
was threatened with a pulmonary phthisis and only escaped
with his life by abandoning his labors and by careful treat-
ment and systematic change of climate. It is easy to fore-
see the probable fate of the subject of this history under
unfavorable circumstances, for there is every reason to be-
lieve that we have here an individual afflicted from child-
hood with a nasal disease due to a malformed septumj
doubtless hereditary in character. I infer the hereditary
character of the complaint from the peculiar form of the
deviated septum already pointed out, from the fact that the
brother and several ancestors of the patient were afflicted
with -pulmonary phthisis, and for other reasons already
given.
Treatment. — Measures were at once employed to relieve
the patient of the discomfort occasioned by the accumula-
tion of muco-purulent matter and crusts in the ample in-
terior of the right nostril. This was readily accomplished
by thoroughly cleansing the nostril with warm detergent
washes, and by the assiduous employment of the cotton
probe. The naris, once renovated and relieved of all offend-
ing substances, was kept constantly clean by the daily em-
ployment of a convenient post-nasal douche, in the use of
which the patient acquired much manual dexterity.
To prevent the adherence of nasal crusts to the sinuosi-
ties of the nostrils, the membrane was bathed at convenient
intervals in a fine spray of vaseline. The douche became
part of the patient's daily toilet, and he soon ceased to feel
any discomfort except in the right nostril. A sense of op-
pression from his inability to breathe through this side in-
creased his desire to obtain any relief offered by a surgical
remedial measure. I therefore operated with this intent,
leveling the deviated structure. This included a portion of
the vomer as well as the deflected triangular cartilage. I
employed my tubular forceps, fenestrated cartilage forceps,
and rongeur or bone forceps. There were two sittings of
about an hour each. The use of cocaine upon the patient
was particularly satisfactory. A ten-per-cent. solution was
applied in the form of a spray, and the parts in two or three
minutes were so completely benumbed that bone and carti-
lage were crushed at short intervals without the slightest
manifestation of pain. I have noticed a singular obtuseness
to pain in other cases in which cocaine has been applied to
an anaemic mucous membrane.
Fig. 9, taken from a life-sketch, shows the deviated sep-
tum anteriorly, and Fig. 10 the same after operating. Nasal
respiration was completely re-established through the ste-
nosed nostril, and this and the relief from other catarrhal
complications left the patient in a most excellent condition
— almost, in fact, unconscious of his trouble.
He embraced a good opportunity, and is now traveling
abroad ; on his return he will arrange to spend the winter
JARVIS: NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS. [N. Y. Mei>. J
292
farther south than New York. Under the favorable condi-
tions afforded by physical ease and a suitable climate the
chances of this individual escaping the ravages of tubercu-
lar phthisis appear most excellent.
Pig. 10.
Case II. — Mr. , merchant, aged thirty-one, from
Owego, N. Y., consulted me in January, 1884. The patient
distinctly recollects having suffered with a nasal catarrh
seven years ago. Although the affection at that time proved
troublesome, still the excellent state of his general health
induced him to consider the malady as trifling and transient
in character. Small quantities of phlegm were constantly
hawked up from behind the palate. There was a disposi-
tion to clear the windpipe of particles of viscid matter.
At that time and for several years subsequently he plowed
the fields as a farmer.
The catarrhal symptoms, instead of disappearing, as he
had hoped and expected, became more pronounced and
troublesome, and, his stomach becoming incidentally in-
volved, dyspepsia was added to his misery. The prolonged
physical and mental discomfort resulting from the persist-
ent catarrhal disturbances ultimately sapped his energy and
strength, rendering him unfit to pursue his usual occupa-
tions.
Clammy night-sweats commenced last summer, and have
continued with varying frequency and severity since then.
Becoming alarmed about himself, he was easily induced to
seek medical advice.
Prominent among the symptoms given me at the first
interview was a cough, which had, however, commenced
only about a year ago. Phlegm was expectorated with the
cough, particularly on rising in the morning. The cough,
though annoying, was not painful. Six months ago only
a pellicle of mucus was raised in coughing. There is now
a disposition to draw flakes of mucus from behind the soft
palate.
Examination. — General thickening of the nasal mucous
membrane, post-inferior turbinated hypertrophy (dextra).
The usual inflammatory redness of chronic hypertrophic
coryza is replaced by the pale, anaemic hue peculiar to
atrophic catarrh. The same pallor occurs upon the mu-
cous membrane of the throat, larynx, and trachea. A livid,
circumscribed, inflammatory process is visible upon the edge
of the left true vocal cord.
Percussion furnished pronounced dullness over a large
extent of the chest. The resonance on the right side was
higher pitched than on the left. Auscultation demonstrat-
ed the presence of numerous fine crepitant rales diffused
throughout the right lung and commencing in the left ; also
cog-wheel respiration, etc.
The patient, though feeble, was able to exercise in the
open air and to visit my office. This, however, was in ac-
cordance with his own wish. Indeed, he seemed to dread
nothing so much as confinement to the house — a natural
feeling for one who has largely led an out-of-door life. The
unusually cold and inclement February weather severely
tried the patient's feeble powers of endurance, and with the
decrease in his appetite and strength there was an increase
in the copiousness and frequency of the night-sweats. I
foresaw the patient's rapid decline under these unfavorable
surroundings. He followed my advice and went South to
escape the harsh wintry weather, and possibly to prolong his
life a little. On the advent of the warm weather he returned,
passing through New York on his way home. I then ex-
amined his chest and found that the fine rales had become
generally diffused throughout both lungs. The patient
safely reached home and died, near the middle of the sum-
mer, surrounded by his family.
Remarks. — The important and instructive features of
this case are, first, the history of a long-standing catarrhal,
affection (of at least seven years' duration) preceding any
symptom referable to the lungs. Although not holding my-
self in abeyance to the history of patients as given by them-
selves, still the exceptional intelligence displayed by this in-
dividual in relating his symptoms, and their agreement with
the local findings, induces me to believe that the nasal catarrh
preceded the pulmonary disease. In other words, in the com-
bined constitutional depression and pulmonary irritation,
resulting from the mental and physical wear and tear, respi-
ratory disturbances, dyspepsia, etc.,, following in the train
of a long-neglected nasal catarrh, we recognize the precursors,
of a fatal pulmonary tuberculosis. The peculiar blanching
of the intra-nasal mucous membrane, and also of the phar-
ynx and larynx, afforded additional evidence of the exist-
ence of a pulmonary phthisis secondary to a hypertrophic
rhinitis. Such an appearance is just the opposite to what
we might expect to find in this affection, and therefore
indicates the ansemia of phthisis, for, although the catarrhal
hyperemia had entirely disappeared, its pre-existence is
presumable from the presence of the more persistent prod-
ucts, namely, the intra-nasal hypertrophies.
The circumscribed congested area upon the right vocal
cord probably resulted from the rasping character of the
efforts constantly employed to clear the larynx of irritating
''mucus. Its very existence constituted an additional source
of irritation, and, although not to be designated as an ulcer,
it is highly probable that this abraded surface would have
eventually proved to be the starting-point of a phthisical
process, in accordance with a pathological process already
described by me.*
Case III. — Mr. , aged fifty-three, from Ohio, came
to me, through the recommendation of his son, a patient
referred to me by Dr. M. J. Roberts, of New York, in quest
of relief from an annoying nasal catarrh. The malady had
existed for many years. Much discomfort was caused by
* "Archives of Laryngology," vol. iv, p. 187.
Sept. 12, 1885.] JARVIS: NASAL CATARRHAL AFFECTIONS AS A CAUSE OF PHTHISIS.
293
the constant efforts required to remove a constant accumula-
tion of thick, tenacious nasal mucus. Examination of the
nostril revealed, among other signs of a rhinitis hypertro-
phica, the presence of an irregularly shaped posterior tur-
hinated hypertrophy, occupying the right post-nasal fossa.
The hypertrophy exhibited no signs of active congestion,
but was dark-blue in color, evidently indicating much pas-
sive engorgement of the turbinated venous sinuses. The
nasal mucous membrane, throughout almost its entire ex-
tent, presented the pallid hue of phthisical anaemia. Ex-
ploration of the chest demonstrated the existence of ca-
tarrhal phthisis, most markedly developed at the apex of
the right lung.
Believing the posterior hypertrophy to be responsible
for much of the patient's discomfort, I concluded it best to
remove this source of irritation. I employed my nasal
ecraseur, easily encircling the hypertrophied tissue with a
loop of No. 5 piano-wire. As might naturally be anticipated
from the blanched appearance of the pituitary membrane*
the operation was a bloodless one. The patient pronounced
himself much benefited by the operation and after-treat-
ment, and returned to his home well satisfied. This was
in January, 1881. In July, 1882, I was informed that he
had caught cold and was carried off by an attack of pneu-
monia, thus confirming my suspicions that his pulmonary
phthisis would eventually lead to his death.
The son of the deceased, a man about thirty years of
age, had, as I have already indicated, consulted me for
relief from a chronic coryza. The coryza, I discovered,
was due to an hereditary malformation of the septum and
nasal chamber. I succeeded in rendering him compara.
tively free from his complaint by removing the offending
deviation of the septum. He has enjoyed excellent health
ever since. It was interesting and instructive to note the
close resemblance between the forehead and face of the
father and son. The frontal prominences of both pro-
jected so far forward as to place the forehead almost on
a vertical plane with the face. The face beneath the over-
hanging forehead appeared unnaturally narrow, affording
an example of Blumenbach's observation of the marked
retrocession and contraction of the bones of the face in
individuals exhibiting great cranial development.
The father was an intelligent man, and his son, utilizing
excellent educational opportunities, developed unusual liter-
ary ability as the editor of a journal. The youngest, and
only other son of the family, about whom I was consulted
but never saw, I am informed possessed a rare degree of
intelligence, and have a right to suspect that he possessed
the cranial conformation of his father and brother.
A few days ago I was informed that this son had just
fallen a victim to consumption. Despite the" discouraging
family history of the surviving son, I feel confident that
timely treatment and care have sufficiently removed the im-
press of his unfortunate inheritance to enable him to live
out his natural life.
Here, then, we have the mournful picture of a father,
afflicted with a life-long catarrhal malady, eventually perish-
ing with pulmonary tuberculosis, his eldest son harassed
by a nasal catarrh traceable to a deviated septum, and an-
other son, a young man, dying two years after the father
with the same disease.
I might add other illustrations to the foregoing cases
did not the typical character of those just reported make
this unnecessary.
Treatment. — The treatment of these and similar cases is
essentially one aimed at the direct cause of the disease —
namely, the deviated septum and co-existing turbinated hy-
pertrophies. It largely consists in the restoration of nasal
symmetry by methods which facilitate the excision of bone
and cartilage, and the removal of infra-nasal redundancies.
A variety of instruments are therefore required, their char-
acter being determined by the density and situation of
the offending structures. My regular office operating-set
consists of my wire-snare nasal ecraseur, and transfixion-
needles for removing soft redundancies ; a fenestrated carti-
lage forceps, tubular-spring forceps, beaked scissors, and
trimming scissors for excising cartilage ; and my rongeur
forceps for cutting through bone. Nearly all the operations
indicated by these instruments are, through the benumb-
ing influence of cotfaine and rhigolene anaesthesia, rendered
bloodless and painless. Most of you are acquainted with
my methods of operating, and, inasmuch as more than a
mere reference to them would exceed the limits and not
accord with the purpose of this paper, I must refer those
ignorant of these procedures to my earlier publications.
Appropriate treatment should also be instituted to heal
and contract the raw surfaces, to remove and prevent the
reformation of nasal crusts in the atrophic forms of the
disease, and to check excessive discharges of nasal mucus.
In other words, to borrow an expression from Niemeyer,
" Where there is the slightest suspicion of a predisposition
to consumption, every catarrh, no matter how slight, is to
be treated with the utmost care, which is not to be relaxed
until the catarrh is entirely well."
Conclusions. — Briefly reviewing the subject-matter I
have just presented, you will observe that, in determining
the relations of nasal catarrh to pulmonary phthisis, I have,
in the order of its origin and sequence, commenced by ob-
serving and interpreting the catarrhal manifestations as
they occur in the nares, and have traced the gradual exten-
sion of the nasal disease to the larynx.
Within the larynx we discovered the catarrhal impress
in the form of a chronic irritative hyperemia of the larynx,
brought about by the combined action of nasal discharges,
habitual mouth-breathing, and inflammatory changes, chron-
ic catarrhal hyperemia of the larynx ; to go a step further,
ofttimes merges into an acute laryngitis, and this in turn
may develop bronchitis. We recognize the deviated sep-
tum as a most common cause of nasal catarrh, producing
this disease by pressure irritation, interference with nasal
drainage, and unequal distribution of the nasal respiratory
function. We have seen the importance of heredity as a
factor responsible for the existence of certain forms of devi-
ated septa, and noted the conditions indicating the heredi-
tary character of these abnormalities.
Viewing the larynx as really the upper portion of the
lung, although divorced from it on artificial anatomical
grounds, we are often enabled to determine approximately,
294
HALSTED : COMMENTS ON THE USE OF GOOAINE.
[N. Y. Med. Jock.,
by the appearance of the laryngeal and tracheal mucous
membrane, what conditions may exist beyond the line of
laryngoscopic vision, and thus complete our pathological
picture, beginning in the nares and ending in the lungs.
It is hardly necessary for me to insist upon the value of
the lessons to be derived from the early recognition of the
clinical facts I have just presented. They at least offer
something tangible as regards prophylaxis against phthisis
or tuberculosis, for their successful treatment falls in the
positive domain of surgery. The results are for the most
part favorable and speak for themselves, provided the meth-
ods which I have proposed and published for removing re-
dundancies or the remedying of defects are not commenced
too late.
It is hardly necessary for me to add that great care
should be exercised to properly discriminate between cases
in which pulmonary phthisis or tuberculosis precedes or
exists with nasal catarrh, and are, therefore, not related to
the last mentioned affection as cause and effect, and those
developed by a catarrhal affection. Being mindful of this,
I have felt the necessity of sometimes giving details which
were indispensable but which may have been wearisome.
It must also be borne in mind that errors are likely to creep
in from difficulty or carelessness in differentiating distor-
tions of the septum resulting from injury from those de-
pendent upon heredity. My experience, however, encour-
ages me to state that, different from what you might proba
bly imagine, in most instances, such a distinction, when
properly made, constitutes a simple question of differential
diagnosis. I have already referred to some of the rules
which facilitate the recognition of the septum of heredity ;
and, were it advisable just here, I could mention other cri-
teria of equal value. It is obvious that, in treating a sub-
ject of this kind, many questions present themselves, the
proper interpretation of which must, for the present at least,
baffle scientific investigation — such, for instance, as the
proneness of some families with malformed septa to phthisis
or tuberculosis, while others, on the contrary, are afflicted
with annoying sthenic but, as far as the life of the individ-
ual is concerned, harmless pulmonary maladies. These,
among similar speculations, though perhaps partly explain-
able by ingenious hypothetical methods, must, nevertheless,
for want of sufficient demonstrative and experimental evi-
dence, prove for the most part unintelligible. But even in
the contemplation of such obscure problems the earnest
investigator may derive encouragement from Prof. Huxley's
remark, that " whatever may be men's speculative doctrines,
it is quite certain that the order of nature is constant, and
that the chain of natural causation is never broken."
25 East Thirty-first Street, N. Y.
The American Social Science Association held its annual meeting
at Saratoga Springs on Wednesday, September 9th. Papers were read
by Dr. Lucy M. Hall, of Brooklyn, on " The Physical Training of
Women " ; by Dr. D. A. Robinson, of Bangor, Me., on " The Therapeu-
tics of Exercise " ; by Dr. Grace Peckham, of New York, on " The
Influence of City Life on Health and Development " ; and by Dr. Charles
Harrington, of Boston, on " The Adulteration of Food, particularly in
Cities." Other papers were read by Miss Marian Talbot and Mr. C. F.
Wingate.
PKACTICAL COMMENTS ON THE USE AND
ABUSE OF COCAINE;
SUGGESTED BY ITS INVARIABLY SUCCESSFUL EMPLOY-
MENT IN MORE THAN A THOUSAND MINOR
SURGICAL OPERATIONS.
By WILLIAM 8. HALSTED, M. D.
Neither indifferent at to which of how many possibili-
ties may best explain, nor yet at a loss to comprehend, why
surgeons have, and that so many, quite without discredit,
could have exhibited scarcely any interest in what, as a
local anaesthetic, had been supposed, if not declared, by
most so very sure to prove, especially to them, attractive,
still I do not think that this circumstance, or some sense
of obligation to rescue fragmentary reputation for surgeons
rather than the belief that an opportunity existed for assist-
ing others to an appreciable extent, induced me, several
months ago, to write on the subject in hand the greater
part of a somewhat comprehensive paper, which poor health
disinclined me to complete.
In the mean time we have been reading of unsuccessful
and occasionally fortunate hypodermic experiments with
cocaine, without finding a hint as to possible causes for the
very positive contradictions, or even an intimation that
they were not precisely such as must have been expected.
And just now appears a frank confession from Dr. Gar-
rigues,* who narrates his case with so much care and in
such detail as to permit one to say positively why cocaine
in this instance should have proved inefficacious and have
seemed inert, and as to encourage me to do this, and then
perhaps to recommend attention to a few of the facts about
cocaine which in the records of my personal observations
are styled useful, preferably such a3 may enable us to better
recognize proper conditions and cases for its employment,
having indicated methods which insure success.
Like most other contributions to cocaine's subcutaneous
scrap-bag, the latest stakes its own and the drug's reputa-
tion on the luck of a single experiment; and again, like
many of them, records the " failure of cocaine hydrochlorate
to produce anaesthesia." Were success, however, and not
failure, the rule, less conspicuous would the occasion have
become for any one (of the majority) to publish the reasons
why cocaine injections should have accomplished nothing
for a few others (the minority), and as much feebler the ex-
cuse for circulating the results of inexperience, as the pos-
sibilities to continue unformed had been reduced. All things
considered, the journal contributions and personal commu-
nications, the interrogations and opportunities for observing
the methods of others, incline me to regard the ultimate
conviction of Dr. Garrigues as a fair expression of average
notions on the reliability and practical value of subcutaneous
injections of cocaine.
I feel sure, furthermore, that the aforesaid observer will
be gratified at finding his communication offered up in ex-
planation of honest differences of opinion.
*"N. Y. Med. Jour.," August 29, 1885, p. 240, "Failure of Co-
caine Hydrochlorate to produce Anaesthesia," by Henry J. Garrigues,
M. D.
Sept. 12, 1885.J
BOOK NOTICES.
295
Proposing to enlarge an artificially small vaginal orifice
by incision, he. says (loc. cit.) :
" Since here was only a thin layer of skin and mucous
membrane to be cut, both surfaces of which were easily
accessible, it seemed to be a case peculiarly well fitted for
local anesthetization. I began by painting both surfaces
with a four-per-cent. solution of hydrochlorate of cocaine.
When two grains of the salt had been used in this way
and there was not the slightest diminution in the sensi-
tiveness of the skin, I injected a quarter of a grain hypo-
dermically into the tissue to be divided, and continued
soaking the skin and the mucous membrane."
While in sympathy with Dr. G.'s desire to test, where
convenient, the statement of others by an observation of his
own, it is not so evident why he should expect cocaine, in
this particular instance, to make an exception in his favor.
For, when it has been repeatedly observed that a four-per-
cent, aqueous solution does not anaesthetize the sound skin,
fresh demonstrations of the fact should not cause surprise.
" About seven minutes after the first hypodermic injec-
tion I repeated it, introducing the needle from the posterior
commissure all the way back as far as the tissues were to
be divided. In spite of the previous injection, this caused
as much pain as if nothing had been done before to produce
anaesthesia."
Injected under the skin, cocaine probably produces
anaesthesia of the same only when made into or very near
a nerve-filament or nerve-trunk ; and then, according to cir-
cumstances, the anaesthesia persists, more or less complete,
from ten minutes to an hour or more. After an injection
into the skin, the anaesthetic effects seldom last more than
two or three minutes, and often vanish in less than a
minute.
If Dr. G. injected strictly under the skin, he might, by
chance, have paralyzed some nerve-filament; but there is
scarcely a possibility that its distribution could have corre-
sponded to the line of the incision, and a strong improba-
bility that any filament was encountered, because no trace
of anaesthesia remained.
On the other hand, it would be strange if none of the
solution had been forced into the skin layer of this thin
membrane ; in fact, judging from the description of the
part, I doubt if one could have avoided doing so. We may
suppose, therefore, that certain areas of skin were anaesthe-
tized for two or three minutes, and that the operator, by
waiting seven minutes, lost his opportunity.
In the light of a little experience, such events would
not be regarded as unusual.
" This second time, likewise, a quarter of a grain of the
salt was injected slowly, while withdrawing the needle, over
the whole tract with which it came in contact. Finally I
bathed again the two surfaces until I had used in all five
grains of hydrochlorate of cocaine, one half grain of which
had been injected hypodermically. This application of a
four-per-cent. solution had then been kept up for twenty-
five minutes."
Here, again, the incision should have been made as soon
as possible after the injection, and the latter into, not under,
the skin.
" In spite of this thorough and protracted application of
a comparatively strong solution of cocaine, the sensibility
was not lessened the least, so far as the complaints and
screams of the patient could be used as a measure of her
pain."
There suggests itself the propriety of testing the sensi-
bility before cutting.
(To be concluded.)
§0oh Itotkes.
Praktische Beitrage zur Kinderheilkunde. III. Heft. Die
Verdauungskrankheiten der Kinder. Von Dr. Adolf Ba-
ginsky, Privatdocent der Kinderheilkunde an der Univer-
sitat Berlin. Mit 3 Tafeln mikroscopischer Abbildungen.
Tubingen : H. Laupp, 1884. Pp. 232. [Price, 6 M.]
This monograph, the third of the series, contains a thor-
ough and quite exhaustive discussion of the commoner diseases
of the digestive system, the rarer forms not being noticed.
It is divided into five chapters, in which are described, re-
spectively, primary dyspeptic gastro-intestinal catarrh, acute
gastro-enteritis (cholera infantum nostras), acute follicular en-
tero-colitis, secondary subacute or chronic gastro-intestinal
catarrh, and gastro-intestinal atrophy (atrophia infantum). The
author's investigations into the subject of astiology lead him to
the conclusion that these diseases are not influenced by sex,
atmospheric pressure, rainfall, fluctuations in ground water, or
dentition. The great causes are the heat of summer, the mode
of feeding (five sixths of the fatal cases being in those who were
fed artificially), and age. Over ninety-five per cent, of the per-
sons who died of diseases of the digestive organs in Berlin were
under five years of age.
Special attention has been paid to the pathological side of
the subject. Both the gross and the microscopical lesions are
exceedingly well described, and twenty-nine original drawings
are given in an appendix illustrating the microscopical appear-
ances of organs, discharges, and microbes. Into the investiga-
tion of the question of bacilli he has entered quite fully. The
dejections furnished an immense number and variety of micro-
organisms. The most characteristic in the simple gastro-intes-
tinal catarrh were little rods and cocci, their number varying
with the development of the case. In true cholera infantum
the bacilli most abundant were broken rods, not stained easily
by either Bismarck-brown or gentian- violet, but best seen by
adding liquor potassae to the fresh specimen. These were found
very constantly both in the walls of the intestine, particularly
in the lymph vessels and follicles, and in the dejections. Al-
though the author has as yet made no experiments with culti-
vations from this bacillus, he is strongly inclined to regard it as
the cause of the disease.
In the treatment of simple catarrh, after the bowels have
been cleared by either castor-oil or an enema, antiseptics are
relied upon very largely to control the disease. Of these he
prefers resorcin to all others, giving it in doses up to one grain
every two or three hours to a child a year old. Large doses of
this drug are not to be used. Iodoform in one- or two-grain
doses he has found of value, and also bismuth. Opium may be
advantageously combined with any one of these three drugs.
It is specially indicated where increased peristalsis is a promi-
nent symptom. It favors rather than prevents decomposition.
Simple and astringent enemata are highly spoken of in almost
all forms of diarrhoeal disease, but especially in cases of colitis.
296
BOOK NOTICES.
[N. Y. Mud. Jonu.,
One or two grains of nitrate of silver are added to each enema
in cases of frequent mucous and bloody stools, tincture of
opium when the tenesmus is great — injected with water, never
with starch. Injections should be made through a soft catheter
or a rectal tube carried high into the bowel.
In choleraic diarrhoea astringents are useless. The prog-
nosis is bad under almost any treatment, but the best results
are reported from free stimulation, hypoderrnically if the vom-
iting is persistent, and irrigations of the bowel.
The author takes issue with Biedert regarding the existence
of " fat diarrhoea" as a peculiar form of disease. Fat is found
in the stools of every child suffering from indigestion while
nursing; it may be present in very large amount without any
diarrhoea. Examination of the pancreas has so far, in his own
cases, been without result.
The diagnosis of gastric indigestion is to be made, lie states,
not so much from the condition of the vomited matters in
curds, or their sour reaction, as from the fact that food undi-
gested is vomited at a considerable time after it is taken. The
stomach of a nursing infant should be empty in an hour, or at
least in an hour and a half, after taking food.
The last chapter, upon atrophy, is exceedingly good. The
stools in this form are pasty and homogeneous, alternating with
those which consist almost entirely of watery elements. They
all have an exceedingly foul odor, and particles of food are not
visible; they contain no epithelium and no cell-elements. The
food is not digested, but its appearance is completely destroyed
by decomposition. The lesions well explain the symptoms,
especially the extreme emaciation which exists. There is an
extensive proliferation of new connective tissue in the submu-
cosa, and the contraction of this and pressure upon the glan-
dular structures leads to the destruction and disappearance of the
latter, so that neither absorption nor secretion can take place in
the bowel. The condition is a hopeless one when it is reached.
This book is worthy of a more extended review than our
space here will permit. Throughout the author shows a prac-
tical grasp of his subject. We should like to see the book given
to American readers in a translation.
BOOKS AND PAMPHLETS RECEIVED.
Poisons: their Effects and Detection. A Manual for the
Use of Analytical Chemists and Experts. "With an Introductory
Essay on the Growth of Modern Toxicology. By Alexander
Wynter Blyth, M. R. C. S., F. C. S., etc. With Tables and Illus-
trations. Vol. II. New York: William Wood & Co., 1885.
Pp. 668. [Wood's Library of Standard Medical Authors.]
On Renal and Urinary Affections. By W. Howship Dickin-
son, M. D. Cantab., F. R. C. P., etc. Miscellaneous Affections
of the Kidneys and Urine. New York: William Wood & Co.,
1885. Pp. x-343. [Wood's Library of Standard Medical Au-
thors.]
A Practical Treatise on Diseases of the Kidneys and Urinary
Derangements. By Charles Henry Ralfe, M. A., M. D. (Can-
tab.), etc. With Illustrations. Philadelphia: P. Blakiston, Son,
& Co., 1885. Pp. xii-572. [Price, $2.75.]
Proceedings and Addresses at Sanitary Convention held at
Hillsdale, East Saginaw, and Lansing, Michigan, April 17 and
18, 1884, December 2 and 3, 1884, and March 19 and 20, 1885.
[Supplements to Annual Heports of the Michigan State Board of
Health.]
Report of Proceedings of the Illinois State Board of Health.
Quarterly Meeting, Chicago, July 2-3, 1885.
Transactions of the Medical Society of the State of West
Virginia, 1885.
Cholera in Europe in 1884. Reports from Consuls of the
United States.
Transactions of the Louisiana State Medical Society, 1885.
Report on Cholera in Europe in 1884 and 1885. By D. N.
Kinsman, M. D., Columbus, 0. [Reprinted from the " Cincin-
nati Medical News."]
The Latest Systems in Medicine. The Presidential Address,
delivered to the Ohio State Medical Society, June, 1885. By J.
C. Reeve, M. D., of Dayton.
Hydatid Tumors in the Brain. By R. narvey Reed, M. D.,
of Mansfield, O. [Reprinted from the "Journal of the Ameri-
can Medical Association."]
Case of Missed Labor with Caesarean Section. By Stanley
P. Warren, M. D., Portland, Me. [Reprinted from the "Ameri-
can Journal of Obstetrics."]
Les remedes dits specifiques sont des agents antizymasiques.
Lettre adressee a M. le Dr. Dujardin-Beaumetz, par G. Pecho-
lier, professeur agrege a la Faculte de medecine de Montpellier.
Montpellier: Camille Coulet; Paris: A. Delahaye & E. Le-
crosnier, 1885.
Cholera: its Nature, Symptoms, History, Cause, and Pre-
vention, etc. By J. B. McConnell, M. D., Professor of Materia
Medica and Therapeutics, etc., University of Bishop's College,
Montreal. Montreal : Robert Miller, Son, & Co., 1885. Pp. 40.
Case of Poisoning resulting from Chloroform taken inter-
nally, etc. By Llewellyn Eliot, M. D., etc., Washington. [Re-
printed from the " Medical Record."]
Fissura Ani, or Fissure or Irritable Clcer of the Bowel. By
Archer Atkinson, M. D., etc. [Reprinted from the "Journal of
the American Medical Association."]
Floating Minute Organic Matter in the Air, etc. By David
Prince, M. D., Jacksonville, 111. [Reprinted from the " St. Louis
Medical and Surgical Journal."]
The Nature and Treatment of Sporadic and Epidemic Chol-
era. By Alexander Harkin, M. D., F. R. C. S., etc. [Reprinted
from the " Dublin Journal of Medical Science."]
Laryngeal Haemorrhage. By J. W. Gleitsmann, M. D., etc.,
New York. [Reprinted from the " American Journal of the
Medical Sciences."]
Deviation of the Nasal Septum. By J. W. Gleitsmann,
M. D., etc., New York. [Reprinted from the " American Jour-
nal of the Medical Sciences."]
Some Personal Observations on the Work of Lawson Tait,
etc. By A. Van der Veer, M. D., etc., Albany. [Reprinted
from the " American Journal of Obstetrics."]
A Memoir of Charles Hilton Fagge, M. D., etc. Philadel-
phia: P. Blakiston, Son, & Co.
Fourth Annual Report of the State Board of Health of the
State of New Hampshire, for the Year ending April 30, 1885.
On the Importance of Certain Signs in Making the Diagnosis
of Fracture near a Joint. By Oscar J. Coskery, M. D., etc.r
Baltimore. [Pamphlet.]
Seventeenth Annual Catalogue and Announcement of the
Woman's Medical College of the New York Infirmary.
Laws of Maternity. By Nathan Allen, M. D., LL. D., Low-
ell, Mass. [Reprinted from the " New England Medical Month-
ly-"]
Tabular Statistics of One Hundred Cases of Urethral Stric-
ture Treated by Electrolysis, without Relapse. By Robert
Newman, M. D., etc., New York. [Reprinted from the " New
England Medical Monthly."]
Surgical Notes from the Case-Book of a General Practitioner.
By William C. Wile, M. D., Sandy Hook, Conn. [Reprinted
from the "New England Medical Monthly."]
Seventeenth Annual Report of the President of the Ine-
briates' Home, Fort Hamilton, N. Y.
Histero-Ovariotomia Seguida de Curacion, etc. Por el Dr.
' D. Manuel Carceles Sabater. Precedida de un Prologo del Dr.
Sept. 12, 1885.]
CORRESPONDENCE.
29T
D. Rafael Martinez y Molina. [Reprinted from the " Revista de
Medicina y Cirugia Practicas."]
The Mechanical Treatment of Talipes Calcaneus. By A. B.
Judson, M. D., New York. [Reprinted from the " Medical
Record."]
Voice in Singers. By Carl II. von Klein, A. M., M. D., Day-
ton, Ohio. [Pamphlet. — Price, 25c]
Diagnosis and Treatment of Posterior Positions of the Occi-
put. By William L. Richardson, M. D., Boston. [Read before
the Massachusetts Medical Society.]
Hard Chancre of the Tonsil. By Frank Donaldson, Jr.,
M. D., Baltimore. [Reprinted from the "Medical News."]
An Address on Cholera Infantum. By William Perry Wat-
son, M. D., Jersey City, N. J. [Reprinted from the "Archives
of Paadiatrics."]
Twentieth Annual Announcement of the Missouri^Dental
College, St. Louis.
Forty-fourth Annual Announcement of the St. Louis Medi-
cal College.
Annual Announcement of the College of Physicians and
Surgeons, Baltimore.
Seventy-eighth Annual Announcement of the College of
Physicians and Surgeons, New York.
Duty of the State toward the Medical Profession. An Ad-
dress, etc. By Conrad George, M. D., Ann Arbor, Michigan.
[Reprinted from the "Physician and Surgeon."]
The Germ Theory of Disease, and its Relations to Sanita-
tion. By P. C. Barker, M. D., Morristown, N. J. [Extracted
from the "Transactions of the Medical Society of New Jer-
sey."]
C0iT,es|j0ttfjence.
LETTER FROM BOSTON.
The Boston Water - Supply.
Boston, September 8, 1885.
If the newspapers are to be believed, Boston is to-day with,
out a drop of good water to drink. We had just got over our
cholera scare, and were thinking of bringing our families and
patients home, when the Mayor sent a document to the Water
Board which caused considerable consternation. For years we
had been receiving our water from Lake Cochituate, and the
supply equaled the demand, and was good, but, when the sui--
rounding territory was annexed, that supply ceased to be large
enough, even with that from Mystic River (which came to us
through the taking in of Charlestown) and the water from Ja-
maica Pond, Jamaica Plain, and Roxbury; so that, in June,
1874, the Hon. Samuel C. Cobb, at that time Mayor of Boston,
appointed a committee of three physicians to examine and re-
port upon various sources for a" new supply. The committee
consisted of Dr. Charles W. Swan, Prof. Edward S. Wood, and
Dr. Henry P. Bowditch, and they carefully examined the waters
of the Sudbury, Mystic, Shanshine, and Charles Rivers. They
said: "The resultant estimate, therefore, of the sanitary quali-
ties of the four rivers places them in the following order of
preference: 1. Shanshine. 2. Charles. 3. Sudbury. 4. Mys-
tic." On account of superior storage facilities, the Sudbury was
chosen.
It is unnecessary to go into details as to the mechanical part
of the work; but, in order that your readers may have some
idea of how we are supplied now, I will say that the Sudhury
River was diverted from its natural channel, and, by means of
storage reservoirs, Beaver-Dam Brook and Farm Pond brought,
in with the Cochituate system. At the time that the Farm
Pond plan was being considered by the city government, those
most interested in the work wished to have the bottom of the
pond (which was a peaty soil) and the conduits dredged and a
hard bottom of sand and gravel substituted for the loam, main-
taining that such a procedure would greatly benefit the water,
and that the loam could be used by the city in other work it
was contemplating. On account of the additional cost, this-
was not done. The new system had not been long in operation
before a change in the color and taste of the water was noticed.
The taste kept growing worse and worse until the so-called
"cucumber taste" was reached. Many theories were advanced
as to what caused this, but nothing satisfactory was offered
until a gentleman from Baltimore examined the water and re-
ported that this peculiar condition was due to a growth which
took its origin from the peaty soil, the flow of the water being
so slow that the growth was not interfered with. The city
authorities now ordered — what they should have ordered at
first — the removal of the loam and its replacement with sand
and gravel. This done, the cucumber taste disappeared. Dur-
ing this period the hydrant-water was used only for bathing
and cooking; for drinking purposes people bought spring water
from varions sources, and it was astonishing to see the amount
that a few springs would furnish — so that many believed that
charcoal or some other filter was all that was necessary to cre-
ate a " spring."
It is not necessary to go into the politics of the subject and
state how two water boards were suspended on account of want
of confidence, as all this has been amply made public in the-
newspapers. In May, 1884, Dr. Henry J. Barnes, in a paper
upon " Sewerage Systems and the Epuration of Sewage by Irri-
gation and Agriculture," read before the Section of Clinical
Medicine and Hygiene of the Suffolk District Medical Society,
showed that our water-supply was contaminated with the sew-
age of the Woman's Prison at Sherburn, in addition to other
sources well known, from which he had for years been trying
to get relief by legislation. As an outcome of this paper, com-
mittees were appointed by the Norfolk and Suffolk Medical So-
cieties to investigate the sources of our water-supply, and re-
port. They have done so, and their conclusions are not of a
nature to give confidence in the purity of the water. They
state that all the fountain-heads are polluted with the sewage
of villages and towns, which drain either into the soil or di-.
rectly into the brooks from which the supply is derived ; that
numerous factories, tanneries, and other industrial establish-
ments are drained directly into the rivers; and that, even where
screens and filters are used to keep out offensive matter, they
do not act sufficiently to be of service. Of course, these state-
ments have in several instances been denied, and in others the
local authorities assert that the condition of things has been
greatly exaggerated. The fact that our water-sheds are among
thickly settled communities can not be denied. These commu-
nities have to dispose of their sewage, and, no matter how
that is done, some of it must flow into and follow the water-
courses.
This question of water-supply and the disposal of sewage is
one that has been constantly before the community, and various
suggestions have been offered ; but heretofore the trouble has
been that nobody in the city government was really responsible.
Now, by our new city charter, the Mayor is responsible for every-
thing, and Mayor O'Brien has given his word that he and the
Water Board will investigate the subject carefully and thor-
oughly, and, if possible, remedy the trouble, even if it becomes
necessary to take water from Lake Winnepesaukee, and build a
sower from the mountains to the ocean.
298
LEADING ARTICLES.
[N. Y. Med. Joch.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D Appleton & Co. Frank P. Fobteb, M. D.
NEW YORK, SATURDAY, SEPTEMBER 12, 1885.
A PROPOSED NEW NATIONAL MEDICAL ASSOCIATION.
The deep dissatisfaction of the profession with the Ameri-
can Medical Association has found renewed and energetic ex-
pression week by week since we first insisted upon its responsi-
bility for the deplorable prospect now before the Ninth Inter-
national Medical Congress, in case the attempt should yet be
made to hold the session of 1887 in this country. This feeling
of dissatisfaction is deeply tinged with indignation and disgust.
It is entertained by honorable physicians in every quarter of
the United States, as is amply shown by the extracts we have
published of late from a great number of our contemporaries.
It was hoped at first that the unutterably foolish and pre-
sumptuous action taken at New Orleans was in a certain sense
an accident; that it would be rescinded when its real purport
and the disfavor with which it met came to be understood by
the leaders of the association, so that even the success of the
Congress would not be seriously imperiled ; and that the inci-
dent would, in the long run, prove a blessing in disguise by
demonstrating the necessity of taking prompt measures to re-
model the organization. Although we have been quite as de-
cided as any of our contemporaries in denouncing the associa-
tion, we nevertheless shared the hopeful feeling alluded to until
it became evident that the managers of the organization were
determined to give no heed to the voice of the profession. But
it is quite manifest now, not only that the profession at large is
to be disregarded, but that even the members of the association
can not be counted on to continually hold in check the schemers
that control it. Nothing but a radical re-organization would
put it on a satisfactory basis, and the outlook for such a regen-
eration is not promising. It must be conceded, therefore, that
the rapidly increasing number of those who hold that the
American Medical Association " must go " are taking a position
that is not at all unreasonable.
But a national organization of some sort we must have, al-
though the less it occupies itself with politics the better. Sev-
eral suggestions have been made as to the establishment of a
new society, but none of them have struck us as quite so feasi-
ble as one which is outlined in a communication lately sent to
us by a member of the profession who modestly asks us to
withhold his name. We will say, however, that he is a gentle-
man of deservedly high position, and one for whose judgment
those who know him have the very highest respect. Like
many others, who have been falsely accused of being actuated
by a feeling of hostility toward the American Medical Associa-
tion, his present despair of the regeneration of that body has
been slowly brought about, and his proposition would never
have been broached, or even taken shape in his mind, but for
the indisputable and confirmed degeneracy of the association.
Our correspondent thus sets forth his plan : " I think we
need a medical association corresponding to the French Acade-
my of Medicine ; that it should be few in numbers, filling its
own vacancies, and so honorable a body that membership in it
would carry the highest reward that medical men here would
have to hope for. Its annual (business) meeting should be held
always at the same place (? Washington) and at the same time
of year ; its semi-annual, or scientific, meeting movable by vote
of its members from city to city. The original organization
might well take its inception in a small gathering of eminent
physicians, who should send out a circular, signed by a com-
mittee composed of representative men from the principal
cities, inviting the appointment of delegates to a nominating
convention, which should appoint the first half of the Academy.
Let the first half proceed at its ample leisure to fill its own
numbers."
Our correspondent adds that his idea has met with hearty
support from the influential men to whom he has been able to
suggest it. It certainly seems to us feasible and judicious.
Matters of detail would of course come up for settlement in
considerable variety, but the essentials of the plan are such as
could scarcely fail to secure the establishment of a body of men
quite above the petty idea of geographical representation,
creditable to the country from a scientific point of view, and
conservative in the few matters of legislation that they would
tolerate. No fraction, even, of such a body — supposing a meet-
ing to be scantily attended — could be " captured " by schemers
or cajoled by buncombe. The author of this plan says that he
is quite aware that it could not be carried out at once — not
soon enough, indeed, to meet tbe exigency now upon us in con-
nection with the International Congress — but it is for the
future that we must provide. It is not without due considera-
tion that we have resolved to favor the idea, but we do so now
without reserve, and we trust that the profession will take it
into serious consideration. That there is a widespread inclina-
tion to take some such action we have no doubt.
" THE WAY ACROSS IS LONG ; THE FEAR OF THE SEA IS
STRONG."
With this quaint statement of a truism does Prof. Hansen-
Grut, of Copenhagen, whose letter to a New York physician
we publish elsewhere in this issue, tenderly disguise the disgust
that our European colleagues are beginning to feel at the
wretched results of the American Medical Association's med-
dlesome and revolutionary course in the matter of the Ninth
International Medical Congress. But politeness will not long
cover that disgust. How keen a feeling of indignation is en-
tertained in our own country we can not better express
than by quoting from an editorial article in the September
number of the "Pacific Medical and Surgical Journal," of
San Francisco (on the cover of which journal, by the way,
appears the name of R. Beverly Cole, M. D., M. R. C. S., as a
collaborator). Our esteemed contemporary prints Sir James
Paget's letter toDr. I. Minis Hays, and adds the following
comment:
Sept. 12, 1885.]
MINOR PARAGRAPHS.
299
" It will be seen from this that the power of making the necessary
arrangements has never been put in the hands of the British, Danish,
or any other national medical society ; but intrusted to a few men of
established reputation, who co-operated with the Executive Committee
of the Congress. Perhaps the American Medical Association will now
be convinced that they have meddled in a business over which they had
no direct authority; that, in making themselves the instruments of
men who have since boasted of the mischief they have done, they have
struck a blow at medical culture, the effects of which only the lapse of
long years can remove. The ' American Medical Journal ' has vainly
reasoned with and finally abused as obstructionists to the work of or-
ganization those men who have refused to acknowledge the supremacy
of the association. Let us hope that its editor will now see that they
were right in so doing ; that the only men recognized as a committee
by the Medical Congress were the American delegates to Copenhagen ;
that these gentlemen are accountable to the Congress ; that it is now
their duty to utterly ignore the American Association as an organiza-
tion, and continue to make the necessary arrangements for the conven-
ing of the Congress, which, according to the law of usage, it is their
right to do. Should Dr. Billings and his colleagues not recognize the
fact that they are the men intrusted by the Congress with making the
arrangements, that they are answerable to that body, and that the
American Medical Association has absolutely no authority over them in
this matter, then the Executive Committee of the last Congress, which
still exists, and will not be discharged until the next meeting, should
take this matter into its own hands and arrange to hold the meeting in
some other country."
We are sorry to say that the American Medical Association
seems not to have the slightest glimmering of an idea that it
has done anything wrong, although it finds itself at bay, and is
ready to resort to tactics, such, for instance, as what it is
pleased to regard as the compromise involved in throwing the
membership in the Congress (a matter over which it has no
control) open to the whole regular profession, while denying
official positions to all but those it considers its friends. The
eyes of our foreign colleagues are upon us. What will they
think of the secrecy in which last week's committee meeting
was shrouded? Are they not perfectly well aware that, if the
meeting had really done anything calculated to set things right,
the committee would not have concealed the fact, but would
have made haste to publish it? Truly, our friends in Europe
would find the way across long and the fear of the sea strong,
but it looks as if they would not have to encounter either.
NEWS ITEMS, ETC.
The International Medical Congress.— In addition to the
declinations already announced, those of Dr. R. P. Lincoln, of
New York, and Dr. J. H. Kidder, of Washington, have been
sent in.
A special meeting of the American Medical Association's
new committee on the Congress was held at the Murray Hill
Hotel, in New York, on Thursday and Friday of last week.
About thirty members of the committee seem to have been
present from first to last, but probably nothing like that num-
ber at any one time. The utmost secrecy was observed, re-
porters being excluded, and there appears to be ground for the
inference that continued secrecy was enjoined upon those who
were present. Nevertheless, certain facts have become known
— among others, that Dr. Lewis A. Sayre, of New York, ten-
dered his resignation from the committee, that Dr. N. S. Davis,
of Chicago, was made secretary-general of the Congress, and
that the so-called compromise was adopted of allowing all
members of the regular profession to register and pay their
fees, but not to hold office in the Congress unless by virtue of
membership in some society in affiliation with the American
Medical Association.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending September 8, 1885 :
DISEASES.
Week ending Sept. 1.
Week ending Sept. 8"
Cases.
Deaths.
Cases.
Deaths.
Typhus
0
1
0
0
34
3
36
10
13
2
15
■ f'y
Cerebro-spinal meningitis. . . .
2
1
1
i
9
1
3
i
21
11
35
15
M 0,
0
2
0
The Health of Michigan.— In addition to his usual month-
ly statement, the secretary of the State Board of Health has
issued a supplementary bulletin for August, in which he clearly
shows the connection between the board's sanitary work and
the decided decrease that he is enabled to record in the preva-
lence of a number of destructive diseases. The diminished
prevalence of fevers and intestinal diseases is very marked.
Army Intelligence.— Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from August SO, 1885, to September 5,
1885 :
Magruder,"* D. L., Lieutenant- Colonel and Surgeon. Granted
leave of absence for fifteen days. S. 0. 201, A. G. 0., Sep-
tember 3, 1885.
Middleton, Passmore, Major and Surgeon. Assigned to duty
as attending surgeon at these headquarters, vice Major J.
V. D. Middleton. surgeon, hereby relieved. S. O. 131, De-
partment of the Missouri, August 28, 1885.
Girard, Alfred C, Captain and Assistant Surgeon. Assigned
to duty as post surgeon at Boise Barracks, Idaho Territory.
S. O. 142, Department of the Columbia, August 22, 1885.
Davis, William B., Captain and Assistant Surgeon. Having
reported for orders from leave of absence, assigned to duty
at Fort Porter, N. Y., as post surgeon. S. 0. 183, Depart-
ment of the East, August 28, 1885.
Kane, John J., Captain and Assistant Surgeon. Upon expira-
tion of his present leave of absence to be relieved from duty
at Willet's Point, New York Harbor, and to report to com-
manding general, Department of Texas, for assignment to
duty. S. 0. 201, A. G. 0., September 3, 1885.
Banister, John M., Captain and Assistant Surgeon. Assigned
to temporary duty at Camp of Competitors, at Creedmoor,
N. Y., arriving not later than September 4, 1885. S. O. 58,
Division of the Atlantic, August 31, 1885.
Richards, Charles, Captain and Assistant Surgeon. To be
relieved from duty in Department of the East, and to report
to the commanding officer at Willet's Point, New York Har-
bor, for duty at that station. S. 0. 201, 0. S., A. G. 0.
Kendall, William P., First Lieutenant and Assistant Surgeon
(recently appointed). To report in person to the command-
ing general, Department of California, for assignment to
duty. S. 0. 201, A. G. O., September 3, 1885.
300
LETTERS TO TEE EDITOR.— PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jofe.,
Society Meetings for the Coming Week:
Monday, September lJ^th : New York Ophthalmological Society
(private); New York Medico-Historical Society (private);
New York Academy of Sciences (Section in Chemistry and
Technology); Boston Society for Medical Improvement;
Gynaecological Society of Boston; Burlington, Vt., Medical
and Surgical Cluh ; Norwalk, Conn., Medical Society (pri-
vate).
'Tuesday, September 15th: New York Academy of Medicine
(Section in Theory and Practice of Medicine) ; Medical Soci-
ety of the County of Kings; Ogdensburg, N. Y., Medical
Association ; Connecticut River Valley Medical Association
(Bellows Falls, Vt.).
"Wednesday, September 16th: Northwestern Medical and Sur-
gical Society of New York (private); Medical Society of the
County of Allegany, N. Y. (quarterly) ; New Jersey Academy
of Medicine (Newark) ; Philadelphia County Medical Soci-
ety (clinico-pathological).
Thursday, September 17th: New York Academy of Medicine;
New Bedford, Mass., Society for Medical Improvement (pri-
vate).
Friday, September 18th: Chicago Gynaecological Society.
Saturday, September 19th: Clinical Society of the New York
Post-Graduate Medical School and Hospital.
fitters 10 % (Sfliior.
SMALL-POX AND VACCINATION.
Franklin, Pa., August 1, 1885.
To the Editor of the New York Medical Journal:
An editorial in your valuable journal of date August 8th, on
the important subject of vaccination after the beginning of
small-pox, induces me to ask the privilege of recording therein
.the following experieuce of my own :
On Monday I was called to see J. H., a farmer, who had
returned home Saturday night sick. He was covered with an
eruption which I thougbt was probably small-pox. The family
of four children were removed from the house, leaving the old
mother, his wife, and a babe of three months to occupy the
same room with him. The mother was said to have been vac-
cinated ; the wife and babe had not been.
On Tuesday I returned with a portion of a fresh crust of
vaccine virus. I vaccinated the three with a small spring vac-
cinating lance, making probably six strokes, and beginning
above. Wednesday the same was repeated lower down. Thurs-
day, also, the same again, still lower. Sunday following the
husband died of confluent small-pox, the wife, the babe, and the
grandmother having occupied the room all the time, and the
mother and babe slept in the bed with the patient.
The vaccination of Tuesday failed on all, that of Wednesday
took effect on the babe and grandmother, and that of Thursday
on the wife. The old woman had a few pustules of varioloid ;
the babe, a smart fever and a dozen or two pustules, which
aborted promptly without pitting. The wife had no fever
nor aDy sign of pustule ; her vaccination was severe and the
areola large, and she entirely escaped, though she had occupied
the same bed with her husband for five successive nights pre-
vious to her vaccination, and for at least three nights after the
smell and eruption were distinct, and would, I believe, be con-
sidered ripe enough to propagate the disease.
I have since, in four cases, vaccinated daily small-pox pa-
tients before the eruption was perfected, marking the lance
strokes. In two of these, which turned out mild cases, the
vaccination appeared to have some effect, as I thought, in modi-
fying the severity of the disease. In the other two the lance
strokes produced no effect, nor did the pustules of small-pox
show on the cuts. But the experience in the four cases was
such as to favor a resort to prompt and efficient vaccination as
a hope of modifying a terrible disease, especially if resorted to
early.
Stephen Bredin, M. D.
fhrjccebmgs of Sanities.
NEW YORK PATHOLOGICAL SOCIETY.
Meeting of June 2b, 1885.
The President, Dr. John A. Wyeth, in the Chair.
A Circumscribed Congenital Tumor of the Leg.— Dr. A.
Jacobi presented a baby, eight months old, whose mother was
sixteen years of age. The baby had a tumor on the outer
aspect of the lower portion of the left leg, extending about one
third of the distance around the leg and upward a distance of
about 5 ctm. ; its surface was a little above the surface of the
surrounding integument. The skin as a whole could not be
raised from the mass, which was of soft feel, and not nodulated.
The tumor had grown slightly since birth. The diagnosis lay
between congenital lipoma and local elephantiasis. The skin
appeared to be hypertrophied, and it was by no means certain
that it was not elephantiasis, which condition he had seen con-
genital in this neighborhood before.
The President asked if it might not be a congenital sar-
coma, and said that he once saw a small congenital sarcoma on
the chin of a boy which had the appearance of a mole or redu-
plication of the integument. After a year and a half the tumor
grew rapidly and the boy died at two years and a half of an
enormous sarcomatous tumor.
Dr. Jacobi thought that by this time the growth, if it were
a sarcoma, would begin to manifest peculiar characters pointing
to that condition. He hoped to have an opportunity to make a
positive diagnosis from a microscopic examination of some of
the tissue.
Salpingo-oophorectomy.— Dr. W. Gill Wylie said that in
January last he presented to the society fourteen specimens of
tubes and ovaries removed by laparotomy for disease of those
organs. This evening he had another series of eleven speci-
mens. The histories were largely similar to those iu the first
series. One of the eleven patients died, making a mortality of
three out of the entire twenty-five cases. In this fatal case, as
in the others, death was due to septic poisoning, and was in
a hospital patient. In all the eleven cases, except two, there
were evidences of local inflammation, and in almost all there
was a history of peritonitis. The majority of the women were
bedridden ; the remainder were laboring women, and unable to
make a living because of their disease. All were under obser-
vation several weeks, months, or a year or more, before the
operation was performed. In reply to Dr. Amidon's question
as to how many of the patients were hysterical, he said proba-
bly one fourth or one third. He was disposed to think those
who had cystic degeneration of the ovaries without disease of
the tubes were the ones likely to be hysterical. He had never
seen a case of hysteria in which there was not found, if lapa-
rotomy was performed, a cyst in the deep stroma of the ovary.
He was beginning to lose faith in the so-called ovarian dys-
menorrhea; in the great majority of cases it was caused by
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OF SOCIETIES.
301
hyperesthesia of the mucous membrane at or near the os in-
ternum.
The President had seen some cases comparatively recently
which had impressed upon him the great importance of two
principles which should be observed in order to obtain success
in abdominal surgery; the first was, to avoid septic matter en-
tering the abdominal cavity; the other, to secure free drainage.
It had usually been taught that rupture of the bladder with
escape of urine into the peritoneal cavity was sure death. He
had seen one case of recovery after washing out the peritoneal
cavity with bichloride solution. In another case, in which the
peritoneal cavity became infected by the escape of matter from
cysts, it was washed out two or three times by being completely
filled with a weak solution of corrosive sublimate, which pre-
vented septic reaction or peritonitis, although the patient died
of exhaustion.
Perineal Section and Internal Urethrotomy for Stric-
ture and Urinary Fistulse.— Dr. 0. H. Knight presented the
bladder and penis removed from the body of a man, forty years
of age, who died from poisoning by cyanide of potassium.
Twelve years ago he had gonorrhoea, and a second attack two
years later. Stricture developed, for which he used a sound
for many years. There also appeared urinary fistuke in the
perinasum, for which he received no treatment until they were
divided by Dr. Knight in 1883, who at the same time performed
internal urethrotomy. Urine ceased to pass by the fistulas
almost altogether after the operation. The sounds were passed
for some time. Subsequently the patient fell, and as a result a
perineal abscess developed, and this was followed by a renewal
of the fistulas. The operation of division and of further enlarge-
ment of the urethra with the urethrotome was repeated, and,
after healing of the wounds, no urine escaped by the fistulas for
five weeks, when a slight dribbling occurred. Shortly after-
ward the man committed suicide. At the autopsy the deep
urethra showed an abscess cavity, capable of containing about
two drachms. In the immediate neighborhood were four fis-
tulas, the largest of which readily admitted a No. 28 sound.
The bladder walls were much thickened, and the capacity of
the organ was markedly diminished. The appearance of the
urethra led him to think the fistulas resulted from rough usage
during the passage of sounds.
Dr. J. H. Ripley had once performed perineal section and
urethrotomy in a man sixty years of age who had not passed
urine by the urethra for six years. The fistulas healed and the
urine was passed by the normal channel.
Fibro-sarcoma of the Naso-pharynx recurring Eleven
Months after Operation. — Dr. R. P. Lincoln presented the
specimen, which had been removed from a lad, seventeen years
of age, on whom he had operated, removing a similar but smaller
growth eleven months ago by the galvano-cautery wire. The
first specimen was presented before the society in October last.
The patient failed to keep his promise to have the cauteriza-
tions repeated, and hence the re-development of the growth,
which was larger and more vascular, and was with considerable
difficulty completely removed. The base was broad. The case
emphasized the importance of repeated cauterizations of the
surface of attachment. In this way he believed all these tumors
which could thus be reached (and he had found none which he
could not thus reach) could be radically cured.
Fracture of the Occipital Bone.— Dr. W. P. Watson pre-
sented the occipital bone of a young man who had probably
received an injury from a stone. The three following days he
was able to work, but on the evening of the third day com-
plained of headache, and sent for a physician, who found him
unconscious. The remaining clinical history was incomplete,
but two or three hours before death there was profuse hasmor-
rhage from the nostrils. There were found at the autopsy a
soft spot on the scalp in front of the occipital protuberance and
infiltration of the scalp with blood. On the right side the oc-
cipital bone was fractured, the fracture extending into the fora-
men magnum; on the left side was a fracture which extended a
shorter distance. There was slight congestion of the surface of
the brain.
Ulceration of the Vocal Bands during Measles. — Dr.
Van Santvoord presented a larynx in which the vocal bands
had become markedly ulcerated during the course of measles.
The child suffered from a pharyngitis and broncho-pneumonia
developing in the course of the exanthematous disease. While
he had not made it a custom to examine the vocal bands in
children who had died during the course of measles, unless there
were symptoms pointing specially to them, he had not supposed
that ulceration of the bands was common. He was, therefore,
surprised to learn, on studying the literature of the subject, that
this complication was very common.
AMERICAN DERMATOLOGICAL ASSOCIATION.
Ninth Annual Meeting, held at Greenwich, Conn., Wednesday,
Thursday, and Friday, August 26, 27, and 28, 1885.
The President, Dr. W. A. Hardawat, of St. Louis, in the
Chair.
(Concluded from page 272.)
Thursday's Proceedings.
Officers for the Ensuing Year were elected as follows :
President, Dr. E. Wigglesworth, Boston ; Vice-Presidents, Dr.
I. E. Atkinson, Baltimore, and Dr. A. R. Robinson, New York ;
Secretary, Dr. G. H. Tilden, Boston ; Treasurer, Dr. H. W. Stel-
wagon, Philadelphia. Dr. E. B. Bronson, of New York, was
elected to membership. It was decided to hold the next meet-
ing the last Wednesday of August, 1886, at Indian Harbor Hotel,
Greenwich, Conn.
Dysidrosis. — Dr. G. H. Fox gave a brief description of two
cases. The first one, for want of a better term, he classed
under this heading. The patient was twenty-nine years of age,
and had always perspired freely. Four years ago the eruption
began on the palms of the hand, and had persisted. The soles
of the feet had also been affected at one time. The skin of the
hands was decidedly thick and had a dark hue, and was dotted
with numerous elevations of epidermis, averaging in size that
of a hemp-seed. The patient had never seen any moisture in
connection with this. There had been no itching. The skin
never peeled off. Puncture with a needle revealed no serum or
fluid of any kind.
The second case was that of a woman aged forty-five, a
cook, whose general health was good. The present trouble
began five years ago. The eruption was on the face, and con-
sisted of numerous large and small vesicles containing clear
fluid.
Mycological Studies in Tinea Favosa and Tinea Tri-
chophytina. — Dr. A. R. Robinson, of New York, prefaced a
paper on this subject with a few general remarks. The epider-
mis of different individuals differed in susceptibility to these
parasites. Children were more apt to suffer with tinea tricho-
phytina and favus, while adults more frequently presented tinea
versicolor. All children were not equally susceptible. In many
cases of parasitic disease there was impaired vitality previous to
the development of the affection. The author then gave an
account of his investigations to determine the exact anatomical
seat of the parasitic diseases in question, and to determine the
changes which they produced in surrounding tissues. The con-
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PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jouh.,
elusion was that in favus the rete was not affected until the
later stages, when ulceration had made its appearance. The
parasite confined itself more particularly to the corneous layer.
The parasite of tinea trichophytina in some cases passed down
into the rete, while in others it did not. A number of sections
were shown under the microscope which illustrated the points
brought out in the paper.
Dr. White would ask the reader what evidence he had that
in ringworm and favus a decreased vitality was necessary.
Dr. Robinson thought that it was found in the fact that it
was exceedingly difficult to cure these affections occurring in
broken-down subjects until the general health was improved.
Dr. White could not agree with the speaker in the impor-
tance of depressed general health as a factor in the production
of these diseases. He had never seen any necessity for internal
treatment in these cases. Where the disease affected the gen-
eral surface of the body it was readily removed, but where it
involved a portion covered with hair it was difficult to cure.
Dr. Piffard agreed with Dr. Robinson that there was a re-
lation between the condition of the general system and the ra-
pidity of development and rapidity of cure of the disease.
Dr. Duhring had always held the view that a particular
condition of the epidermis was necessary for the growth of the
fungus. The majority of cases of obstinate ringworm that he
had seen had been in individuals in poor health, but there were
exceptions to this rule. What this peculiar condition of the
skin was had not been determined.
Dr. Denslow had recently seen a large number of cases of
ringworm of the head and beard, but all the patients were well-
developed, muscular subjects. These were cured without inter-
nal treatment.
The Structure of the Derma and the Development of
Elastic Tissue in it— Dr. C. Hkitzman, of New York, read a
paper on this subject. He drew attention to the fact that
Strieker had now accepted his (the author's) views concerning
the life of basis substance. Dr. Gartner, Strieker's assistant,
who was present at the meeting, had brought an electric-picture
microscope, by means of which these newly discovered facts
could easily be demonstrated to a large audience upon a screen.
There were three varieties of basis structure, differing from each
other in their chemical constituents — viz., the glue-yielding basis
substance proper, producing the spindles within the bundles of
so-called fibrous connective tissue ; the cement substance be-
tween the spindles ; and the elastic substance developing along
the edge of the bundles in advancing age and in some tumors.
All three varieties were traversed by a delicate reticulum of
living matter in connection with the protoplasmic cords, that
filled the interstices between the bundles in the shape of a
comparatively coarse reticulum. Thus it became intelligible
that in morbid processes not only the protoplasm, but also the
basis substance, participated in an active manner. After the
liquefaction of the solid fields of glue-yielding basis substance
the bundles were directly transformed into inflammatory cor-
puscles, from which started every physiological and pathological
new formation.
A Case of Multiple Myomata of the Skin accompanied
with Severe Pain was described by the President. A. B.,
aged thirty-six, married, with healthy children and good family
history, had never had syphilis. His present trouble began a
year ago. Changes in the weather produced pains in the parts
which had since become affected. To relieve these, firm press-
ure was made with the hand. Between the paroxysms, pain
was not produced by pressure. Afterward the lesions presented
themselves. The pains still persisted, recurring at intervals
varying from a day to a week. The attack lasted two or three
minutes and did not return the same night. The growth was
situated on the right side of the back, in the mid-dorsal region,
and the course of the growths was obliquely outward. There
were one or two of the elevations on the left side. Three of
the growths were as large as peas. The others were small.
The epidermis was not abnormal. On passing the hand over
these growths, there was no hyperesthesia, but, on deep press-
ure in the neighborhood of the larger masses, the patient sank
moaning to the floor. One of the larger growths was removed,
and microscopical examination showed it to be composed of
smooth muscular fiber. From a clinical standpoint, the case
bore a close relation to the cases of neuroma which had been
reported. The author concluded that certain new growths in
the skin, accompanied with severe pain, might be widely differ-
ent histological structures. We were not justified in assuming
that a painful tumor of the skin was a neuroma or fibro-neuroma
simply from its clinical history, without a microscopical exami-
nation.
An Unusual Case of Tylosis of the Hands was related by
Dr. R. S. Morrison, of Baltimore. The patient was a negro,
aged thirty-two, muscular, well developed, and apparently
healthy. He was a fireman of a steamer and had occupied this
position for ten years, shoveling coal with the right hand grasp-
ing the upper portion of the shovel and the left hand sliding up
and down the handle. Two fingers of the left hand were worn
off to the second joint, while the other two were going in the
same way, the nails having nearly disappeared. On several
occasions he had drawn pieces of bone from the fingers. There
had been no pain at all connected with the affection. On this
hand there were some large blisters, beneath which there were
red granulating surfaces, which were painless. There was no
history nor evidence of syphilis. Specific treatment had been
used without effect. The man obstinately refused to give up his
work, so that little could be done in the way of treatment.
Dr. Tilden thought there was a good deal of resemblance
between this case and cases of perforating ulcer of the foot, and
this would lead us to suspect a nervous element.
Dr. Wigglesworth remarked that it resembled anassthetic
leprosy in some respects, but differed from it in other points.
Dr. Morrison considered it a strictly local affection from the
fact that the hand which was most exposed to rubbing and to
the heat of the furnace was the one most affected.
Dr. Duhring would be inclined to consider the callosities a
secondary condition. The occupation probably had something
to do with the aggravation of the disease, but, if the occupation
had been different, there would probably have been a similar
change. He would regard it as dependent on some deep change
in connection with the nerves, similar to what occurred in per-
forating ulcer of the foot.
Dr. Morrison could hardly admit that it was an affection of
the nerve in the first place. It might be that the continued
congestion of the skin dependent on the man's occupation had
produced changes in the nerves or other part, which culminated
in this affection. Referring to the literature of the subject, he
had found similar cases attributed to mechanical irritation.
The Relations of Herpes Gestationis and certain other
Forms of Disease to Dermatitis Herpetiformis. — Dr. Duhring
read a paper with this title. Attention was briefly directed to
the author's previous articles on dermatitis herpetiformis, and
to a paper showing its identity with the impetigo herpetiformis
of Hebra ; also to a preliminary note on the relation of this dis-
ease to herpes gestationis and other similar forms of cutaneous
disease, read before the association at the last meeting. The
object of the present communication was to prove the identity
of so-called herpes gestationis with a vesicular variety of derma-
titis herpetiformis, and to show that the term herpes gestationis
was a misnomer, the affection being found in men as well as in
Sept. 12, 1885.J
PROCEEDINGS OF SOCIETIES.
303
women. Secondly, that certain other so-called forms of herpes —
such as herpes pemphigoides, herpes vegetans, herpes pysemicus,
etc., as well as certain cases regarded by the reporters as pecul-
iar forms of pemphigus — must be viewed as examples of this dis-
ease; and, finally, that instances of the same affection were also
met with in literature under the title of hydroa and under divers
other captions. Numerous cases from English, French, and
German literature were cited. The paper was to be looked
upon as supplementary to the preliminary note referred to, and
embodied the results of considerable research into literature.
If the views put forth proved to be correct, a great deal had
been gained for dermatology in bringing these peculiar forms of
disease together.
Dr. White thought that the term dermatitis herpetiformis
was a misnomer. The disease should be called dermatitis multi-
formis. The herpetic element was often wanting.
Dr. Robinson agreed with Dr. White that the term derma-
titis herpetiformis was too restricted, but would prefer some
term which did not indicate the pathology, until the disease was
better understood.
Dr. Hyde said there were reasons why he would disagree
with the last speakers. The term herpetiformis was preferable,
if for no other reason, because it was suggestive.
Dr. Fox showed a photograph of a case which might be mis-
taken for dermatitis herpetiformis — namely, erythema multi-
forme. This disease should be placed in strong contrast with
dermatitis herpetiformis.
Dr. Duhring said the name dermatitis herpetiformis had
been adopted because it seemed the least objectionable. The
herpetiform character of the disease was to his mind character-
istic. The term dermatitis multiformis was already employed
to designate a form of skin trouble.
Mycosis Fungoides.— Dr. Tilden described the case of a
man aged twenty-eight years when he came under observation.
Three years before, several red, desquamating spots had been
observed on the elbows. Several months later erythematous
spots, accompanied with pruritus, were noted. These lesions
retained a dry, scaly character. There were no vesicles or pus-
tules. At the end of a year several red nodules appeared on the
face and throat. These, however, disappeared. Afterward a
small papule appeared on the right thigh, and increased in size.
From this there exuded a thin fluid. This was followed by the
development in many parts of the body, particularly the axillae,
groins, and neck, of similar lesions, in some cases reaching the
size of a hen's egg. After a time there was superficial erosion
of some of the tumors, but these excoriated tumors remained
firm in consistence. Some of the masses which were covered
with epidermis were soft, but there was no evidence of the
formation of pus. There was also indolent enlargement of the
lymphatic glands. The general health continued good. The
patient passed from observation, and died at the end of three
years and a half. The report of the microscopist who examined
the tumors was read. His opinion was that the growths con-
sisted of the formation of lymph tissue in the corium. Refer-
ence was then made to the literature of the subject, and the
various cases, some thirty in number, were given. Sections of
the growth were also presented for examination.
Dr. White said that this patient had been under his care
during the last stages of the disease, and presented the changes
which had been described. Some of the larger growths disap-
peared. During the last months of his life the man was taking
arsenic. Death resulted from the occurrence of diarrhoea.
Dr. KonE said that four years ago ho saw a case of what he
thought was the same affection. A man, sixty-two years of
age, had a multitude of these tumors. Several had been extir-
pated before he came under his care, but there was recurrence
with this fungoid appearance. The man was given arsenic, but
he died from exhaustion. No autopsy could be obtained. As
far as could be detected, there was no affection of the liver or
spleen.
Dr. Morrison had seen a similar case, which was diagnos-
ticated as multiple sarcoma of the skin.
Dr. Fox said that one or two similar cases had been seen in
New York. Should one come under his care, he would try the
effect of chaulmoogra oil. Judging from its effects in other
cases, it should be useful.
The President said that in a case of alveolar sarcoma which
he had reported, the disease had existed fifteen years, but the
clinical features were about the same as they were years ago.
There was marked enlargement of the lymphatic glands. The
general condition was good.
Dr. IIeitzman said that the description of the microscopic*
appearance and the examination of the specimen confirmed him
in the view that this was a case of lympho-sarcoma.
Dr. Sherwell, to show the amount of involution that might
take place, would refer to a case of melano-sarcoma under his
care. The man was treated with arsenic, mercurials, etc. Af-
ter six months' treatment, the tumors had almost entirely dis-
appeared. There was not the slightest evidence of syphilis.
Dr. Fox had seen chaulmoogra oil used in a case of leprosy..
There was now not a trace of leprosy, except the contraction
of the fingers, which was, however, a secondary condition. It
had failed in many cases, but a trial of it was justified in the
chronic inflammatory affections referred to.
Urethral Irritation in the Male as a Cause of Certain
Neuroses and of Acne was the title of a paper by Dr. Denslow,
who first gave a brief review of the cases of contracted meatus
reported by Dr. Otis. He then gave an account of a number
of cases that had come under his observation in which there
were reflex conditions associated with morbid states of the ure-
thra— such as contracted meatus, stricture, and excessive sensi-
tiveness of the prostatic urethra. In these cases removal of the
urethral trouble produced an alleviation or cure of the affec-
tion to which attention had been directed. He also reported
four cases of severe acne in which the same treatment had been
followed by marked improvement or cure. In some of the cases
ergotin was also employed. He simply reported the cases as so-
many observed facts, and did not express any theory. He would
keep the cases under observation, and at a subsequent meeting
give a further report.
Dr. Sherwell thought that acne was largely a reflex disor-
der, but was not in the habit of introducing a sound in every
case of acne. He produced good results with other measures.
He believed in the action of ergot in connection with local appli-
cations, especially in females.
Dr. Hyde thought that many of these patients with urethra
trouble associated with acne had probably been taking balsamic
preparations for some time, and, as a result, had acne.
Dr. Denslow said that in all the cases reported the acne
had existed since puberty. The patients were not hypochon-
driacs, and they were not masturbators. He was satisfied that
no drugs had been used by any of them.
Friday's Proceedings.
Remarks on Electrolysis and other Practical Topics was
the title of a paper by Dr. IIeitzman. The reader spoke very
highly of olectrolytic epilation. For this purpose he used the
Leclanche battery. He employed a needle devised by Leiter,
of Vienna, which permitted the depth to which the needle pene-
trated to be measured. He had had good results from electro-
lytic destruction of dilated blood-vessels in the face, but less
satisfactory resultsin the treatment of port-wine marks, a perma-
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OF SOCIETIES.
[N. Y. Med. Jour.,
nent cure of which was only exceptionally attainable. Sodium
ethyl had been highly recommended for the destruction of an-
gioma of the face, but it was in no way superior to nitric acid.
The author maintained, after observing two hundred cases of
falling of the hair caused by seborrhoea, that the method he
recommended in 1876 gave fair results. This was the applica-
tion of a ten- or twenty-per-cent. ointment of crude oleum rusci
in vaseline and paraffin. For the removal of freckles he used
.an ointment recommended to him by Wertheim, of Vienna :
"White precipitate, ) ,
o i -i. * mx.' a > each 1 drachm;
Subnitrate of bismuth, \
Glycerin ointment 1 ounce.
This was to be applied in a thin layer every other night, and
in from four to six weeks the result would be found to be highly
satisfactory. As to the permanency of the cure he was unable
to state. In regard to the reappearance of hair after removal
by electrolysis, he considered it to be due to the growth of the
fine hairs, which was increased by the transfer to them of the
nutrition which should have gone to the hairs removed.
Dr. Hyde said that, in the removal of hair by electrolysis,
the question was not what the result would be at present, but
what it would be in the future. Electrolysis produced a hyper-
aemia, which tended to stimulate the growth of the remaining
hair. He had found the rectified oleum rusci very valuable.
Dr. Fox had used nitric acid for angioma, making the appli-
cation in the form of small dots, a quarter to half an inch
apart, with great advantage. In one case in which a naevus occu-
pied half the body he had used this treatment with much suc-
cess. In regard to the return of the hair after electrolysis, if
the needle was carefully inserted and gentle traction was made
on the hair, that hair would not return. In some cases there
was a constant increase in the downy hairs from some cause,
but these were exceptional cases. He did not think that the
removal of hairs increased the growth of others. In the case
of a young woman with a heavy beard he had removed, by
actual count, eight thousand hairs. This process had required
two or three years. Since then it had been necessary to remove
only a few dozen hairs.
Dr. Robinson had used a similar ointment for the removal
of freckles, but its effect had been only temporary. He thought
that the growth of the remaining hairs was increased by the
removal of a portion.
Dr. Wiggles woeth had for the past fifteen years used the
following ointment, which was almost identical with that men-
tioned by Dr. Heitzman :
White precipitate, )
Subnitrate of bismuth, \ each 10 Part3 :
Vaseline 100 "
The President had performed the operation of electrolysis
for ten or twelve years, probably longer than any other mem-
ber of the association. He used the irido-platinum needle,
which had the advantage of being bent and was not likely
to pass through the follicle-wall. The moment the follicle was
entered there was an escape of sebum. One case, that of a
woman with a heavy black beard, had been entirely relieved.
Electrolysis with a fine needle afforded a method of getting rid
of freckles. The plan was to dot the surface covered by the
freckle with the needle.
Dr. Heitzman said that the percentage of recurring hairs
was greater in some situations than in others. In the submax-
illary region it was greatest.
Syphilitic Reinfection. — Dr. Taylor read a paper on this
subject. He first referred to the literature, and gave a brief
review of the authentic cases on record, with the names of the
reporters. The number of cases previously reported was be-
tween thirty and forty. To these he added the histories of three
more. A fourth case had been observed by him, but, as the
complete history had not been prepared, it was not given.
Case I. — A barkeeper, aged twenty-five years, was first
seen in 1868, suffering with gonorrhoea. Three years previously
he had had indolent enlargement of the lymphatic glands in the
groins. Examination showed the presence of lymphatic enlarge-
ment in certain regions. Inquiry into the history showed the
existence of a chancre three years before, which had been slow
in healing. About two months later he became sick and suf-
fered with a roseolous eruption, sore throat, falling of the hair,
and rheumatic pains, worse at night. Under treatment he im-
proved, but afterward exhibited a papular eruption. He was
then seen by the late Dr. Van Buren, who pronounced the case
one of syphilis and ordered mercurial treatment. He recovered
after two years, but of his own accord continued the treatment
two years longer. He then remained well until the attack of
gonorrhoea. In February, 1870, he again appeared, presenting
a typical indurated chancre on the pubes. It presented every
evidence of a primary infection. Afterward a papular syphilide
appeared over the body, there were several mucous patches on
the pillars of the fauces, and the throat was red and swollen.
The joints soon became the seat of nocturnal pains. The pa-
tient also presented a form of syphilitic epididymitis. Under
mercurial treatment there was some improvement, but a year
later there were some tertiary manifestations. By 1874 he
seemed very well. During the next three years there were no
evidences of syphilis, but he continued the " mixed treatment."
In the autumn of 1882 it was learned that his good health had
continued and that he was the father of a healthy child. The
child was examined, and no evidence of hereditary syphilis was
detected.
Case II. — In June, 1873, the patient had a typical indurated
chancre, followed by distinct secondary symptoms, which disap-
peared under treatment. He then passed from observation.
In February, 1874, he presented several ulcero-tubercular le-
sions on the outer aspect of the forearm. He then remained
under treatment six months. In January, 1875, he had spots of
thickening of the periosteum of both tibiae. He was again
treated with benefit. In June, 1876, there was a typical indu-
rated nodule on the prepuce, from which indurated lymphatics
extended to the inguinal lymphatic glands. The incubation of
this sore had lasted about twenty days. This was followed by
malaise, sore throat, and swelling of the post-cervical and epi-
trochlear glands. Over the body and arms there was a fine
mottling of a light pink color. The patient then went to
Europe and was not seen until March, 1885, when it was
learned that the symptoms had been well marked, and that he
had been under treatment for them by several Continental phy-
sicians.
Case III. — A man, forty-one years old, had had a typical in-
durated chancre in 1874. There had been inguinal adenitis,
followed by roseola, falling of the hair, and subsequently severe
iritis. He was treated with mercury. In February, 1882, he
returned with a typical hard chancre. In April he became sick,
having rheumatic pains and a mixed erythematous and papular
eruption. In May iritis again appeared. In 1883 he had a late
secondary rash.
These cases were reported with the object of throwing some
light upon the natural history of second infections of syphilis.
In all of them relapsing indurations had been carefully excluded.
Observations on the Oleates. — Dr. Stel wagon read a paper
on this subject. In regard to the chemistry and preparation of
the various oleates, both as to their manufacture by the direct
combination of the acid with the base and by double decom-
position, almost, if not entirely, as much could be found in the
Sept. 12, 1885.1
PROCEEDINGS OF SOCIETIES.
305
English translation of Gmelin's "Handbook of Chemistry,"
published in 1896, as in the writings of the past several years.
Of all the oleates, those of mercury, zinc, bismuth, and lead
had a place in the treatment of diseases of the skin ; and, in
view of their costliness, the seeming unavoidable frequency of
badly made preparations, the disagreeable oleic-acid odor, and
the irritation so frequently observed after their use, it was prob-
able that of these four only the mercuric oleate promised to
retain a permanent value. This last was especially valuable in
ringworm of the scalp, but for inunctions in the treatment of
syphilis it was of doubtful utility, as it was questionable whether
it was absorbed. Oleate of copper, which had been so highly
recommended for ringworm of the scalp, was not comparable
in that affection to oleate of mercury or to tar and sulphur
preparations.
Dr. Wiggles worth had practically renounced all oleates
except the oleates of zinc, lead, and mercury as parasiticides.
Dr. Dtthring's experience with these preparations had been
in accord with that of the reader of the paper. He had em-
ployed the oleate of copper in varying strengths in thirty or
forty cases of ringworm, but it had seemed to exert no influence
whatever. But they had been obstinate cases. Other methods
•of treatment had afterward been tried, and they were finally
cured. As to its efficiency in acuter forms of ringworm, he was
not prepared to speak.
Dr. Heitzman had tried the oleate of copper in chronic cases
of ringworm, without any result, but in the acute cases it cured
after a time. It was not so efficient, howeverHas the prepara-
tion recommended by Dr. Taylor — four grains of bichloride of
mercury to the ounce of tincture of myrrh.
The President had almost entirely discarded the oleates.
Tn some recent cases the oleate of copper had seemed to be suc-
cessful, but in chronic cases it had entirely failed.
A Case of Syphilitic Aphasia and Paraplegia followed
by Death, with an Account of the Autopsy.— Dr. Denslow
read a paper the object of which was to put on record a case in
which an autopsy had been obtained in early syphilitic cephal-
algia. The patient was seen in consultation April 29, 1885.
Two months previously he had begun to suffer with severe
headache, worse at night. There was also a papular eruption.
He acknowledged the existence of a sore six months previously.
Iodide of potassium with chloral had been given. Two weeks
later the patient was free from pain, but it returned in one
month and he stopped taking medicine. Iodide of potassium
was again given, with the effect of relieving the pain. Aphasia
and paraplegia then developed, and the patient died four days
later, within nine months of the initial lesion. At the autopsy,
the dura mater, along the superior longitudinal sinus, was thick-
ened and adherent. There were numerous small gummata in
the pia mater, situated along the right border of the longitudi-
nal sinus and extending back to the fissure of Sylvius. The pia
mater exhibited evidences of simple acute inflammation.
NEW YORK OBSTETRICAL SOCIETY.
Meeting of March 3, 1885.
Dr. E. Noeggerath in the Chair.
Drainage-Tubes. — The Chairman showed a series of drain-
age-tubes for use after laparotomy. The first one was the
straight glass tube known as Tait's, the second was Sims's rub-
ber tube, and the third was one which Dr. Noeggerath had him-
self used on one occasion. The large curved glass tube used by
Hegar was next shown. Its wall was perforated in numerous
places at its lower portion, the openings being not above 1 mm.
in diameter. The advantages of the instrument were its large
size, which not only admitted of free drainage, but allowed a
reflector to be passed into the tube so that the neighboring parts
could be explored. The lateral openings permitted the fluid to
enter the tube readily from all sides. They should not be too
large, as there was danger of the intestines becoming engaged
in them.
The Chairman also gave an outline of the after-treatment
of Hegar's ovariotomy cases. For the first twenty-four or
forty-eight hours the patient received only § ss. of cold water
every hour, then | ss. of sour wine every hour for the next
twenty-four hours.
Dr. J. B. Hunter asked in what case9 such large drainage-
tubes were indicated, and how the inference could be drawn
that there would be so much fluid secreted as to require one.
The Chairman replied that they were used in cases in which
there were extensive adhesions, not only to the parietes, but to
the abdominal viscera. He admitted that the necessity for their
use was rare.
Dr. B. MoE. Emmet asked if it was not difficult to close a
wound after the introduction of so large a tube.
The Chairman replied that, on the contrary, the wound con-
tracted so rapidly that a smaller tube must be introduced imme-
diately after the withdrawal of the large one.
Dr. W. G. Wtlie thought that, judging by his own experi-
ence, the cavity would only drain for a short time. He had
sometimes found it necessary to move the lower end of the tube
about to break up adhesions.
Dr. B. F. Dawson thought that the excessive outpouring of
fluid to which the chairman had alluded might be the ordinary
peritoneal secretion, which, being innocuous, did not require to
be drained away.
Dr. Hunter said that he had used even smaller tubes than
Tait's, and had never found any difficulty in removing all of the
fluid by means of a syringe. He preferred straight tubes, since
they could be carried down to the very bottom of Douglas's
pouch.
Dr. Wylie also favored the use of small tubes.
Dr. W. M. Polk recalled a case, related to him by Dr. Thom-
as, in which a hernial protrusion of the intestine took place
through one of the lateral openings in a drainage-tube.
Hysterectomy for Fibroma.— Dr. H. D. Niooll presented
a fibroid tumor with a portion of a uterus removed by Dr.
Thomas at the Woman's Hospital. The patient gave a history
of profuse haemorrhages. The diagnosis of interstitial fibroid
located in the posterior uterine wall was made, and Dr. Thomas
resolved to perform a myomotomy. The usual incision was
made through the abdominal wall, the uterus was rolled out of
the cavity, and its neck was constricted with an instrument de-
vised for this purpose, consisting of two semicircular pieces of
steel, provided with handles, something like a pair of tongs.
The tumor was found to occupy the posterior wall. An incis-
ion was made down to the capsule, which was opened, and the
tumor was readily enucleated. On relaxing the pressure of the
clamp the hajmorrhage from the wound was so profuse that Dr.
Thomas saw that it would be necessary to remove the entire
uterus. This was then accomplished, the stump (which was
long and rather narrow) being secured with Dawson's clamp.
The patient's condition had been perfectly satisfactory. Dr.
Thomas was for a time under the impression that he was the
first who had followed this method of enucleation, but he now
yielded the priority to Dr. Hunter.
Dr. P. F. Munde said that Schroder had first performed this
operation.
The Cn airman was of the opinion that Martin was entitled
to that honor.
Dr. Honter asked if Martin used drainage.
306
MISCELLANY.
[N. Y. Mkd. Jock.
Dr. Munde replied that he drained the wound through the
vagina in cases where the growth extended down into the pel-
vis or between the folds of the broad ligament.
Dr. B. McE. Emmet asked concerning the relative merits of
myo-hysterectomy and removal of the ovaries as a means of
relief from haemorrhage resulting from the presence of uterine
fibroids.
The Chairman said that the question was not yet settled,
English surgeons being rather in favor of oophorectomy, .while
the Germans preferred hysterectomy.
Dr. Dawson, referring to the fact that his clamp had been
used in this operation, said that his idea in devising it had been :
1. To secure perfect constriction of the stump by an instrument
which should compress it into the form of an ellipse. 2. To
have a smooth lower surface which should allow the external
wound to heal perfectly and to become perfectly adherent to
the stump.
Dr. Hunter said that lie preferred to transfix the stump
with needles and to encircle it with a rubber ligature.
The Cn airman thought that by the use of the clamp the
adhesion of the skin, as well as of the peritonaeum, to the sides
of the stump was secured.
Dr. Dawson explained that he removed the clamp after a
few days and substituted for it transfixion with needles.
Salpingo-oophorectomy.— Dr. Hunter presented the fol-
lowing specimens: 1. A specimen of double hydrosalpinx, re-
moved at an autopsy from a case of cancer of the omentum, the
patient having died from fatty heart several days after the opera-
tion. 2. Pyosalpinx (private case). The patient was a young
single woman who had suffered with extreme dysmenorrhcea.
She had been completely relieved by the operation. 3. A case
at the Woman's Hospital. A married woman who had suffered
greatly from menorrhagia and metrorrhagia, symptoms which
disappeared after operation. 4. In this case the operation was
done for dysmenorrhcea, and was easy. Another case was also
related, but the specimen was not shown. The patient had had
severe haemorrhages. On examining her, Dr. Hunter thought
that he detected a small tumor behind the uterus, and also an
enlarged tube. At the operation a small ovarian cyst was found
upon one side, with an enlarged tube. During the attempt to
remove it, the tube ruptured, and a quantity of foetid pus es-
caped. The opposite tube was so tirmlv bound down by old
adhesions that it was removed with great difficulty. There was
a good deal of haemorrhage, which was not checked until much
time had been spent. In the search for the bleeding points the
operator was greatly assisted by the combined use of a cylin-
drical speculum and the small electric light which had been de-
signed for this purpose. The patient developed septic perito-
nitis, and died on the sixth day.
Dr. Hunter stated, in general, that it was his custom to in-
troduce a drainage-tube if there was much haemorrhage, but it
was soon removed. In regard to the symptomatology of pyo-
salpinx, he said that an important point was that the patieDt
complained of pain just be/ore her periods, excessive flow, and
a subsequent discharge of foetid pus. In one case he had even
seen this purulent fluid escaping from the os. He concluded
with the remark that he now used spray in the operating-room,
although it was not thrown directly upon the wound. This
was a necessary precaution in the presence of a miscellaneous
crowd of spectators ; he also endeavored to have his ligatures
perfectly aseptic.
Dr. Munde mentioned a case which showed the difficulty of
making an accurate diagnosis before operation. A patient was
sent to him with a history of recurrent attacks of peritonitis.
On examining her, he thought he detected an ovoid, fluctuating
mass upon the right side on the left side nothing could be felt
but a diffuse swelling. On opening the abdomen, nothing coukf
be differentiated ; the pelvis was filled with an inflammatory de- 1
posit, in which both ovaries and tubes were indistinguishable [•
The only thing which could be done was to ligate the broac
ligament in two places by carrying a threaded needle deep iutc ,
the pelvis and removing the mass by burning it through with
Paqtielin's cautery. The patient made a good recovery. Dr. ,
Munde admitted that there were cases in which it was possible i
to make the diagnosis of enlargement of the tubes, but it was
frequently quite impracticable. He had at the time a patient
under treatment, on examining whom for the first time he had
discovered a sausage-shaped mass situated on the right of the
uterus. He aspirated this tumor through the vagina and with-
drew about 3 iij of clear fluid, in which was found cylindrical
non-ciliated epithelium. This was undoubtedly a cast of hydro-
salpinx.
Dr. Wylie said that it was not necessary to make such an
exact diagnosis. If a patient had been under observation for
some time, and the subjective symptoms were such as to war-
rant an operation, he did not disturb himself about the exact
condition of the tubes. But, he added, it was possible in many
cases to so clear up the inflammatory deposits by a course of
treatment with boro-glyceride tampons that the diagnosis could
be positively made. He believed that many of the so-called
cases of "thickening in the broad ligaments" were really cases
of enlarged tubes.
B. McE. Emmet, M.D.,
B. F. Dawson, M. D.,
II. 0. Coe, M. D., ex officio,
Committee on Publication.
The International Medical Congress. — Professor Hansen-Grut, of
Copenhagen, who was president of the ophthalmological section of the
last meeting of the Congress, and took an active part in the affairs of
the organization, has written the following letter to a New York physi-
cian :
" I am sorry you have so much bother about the Congress. The
spirit that is at the bottom of the dispute is to me a proof of such ex-
clusiveness as I should not have expected to find in your country. I
will answer to your question :
" 1. That the controversy about codes was never thought of, as we
have nothing resembling your codes of ethics.
" 2. The invitation was decidedly given for the whole medical pro-
fession ; none of us thought of, or even mentioned, the American Medi-
cal Association.
"3. The only qualification required was, that the member be a le-
gally acknowledged medical practitioner in his country. Our homoeopa-
thists who were legally acknowledged practitioners (Dr. Siemsen-Ferish
and others) were actually members, and undisputed members, of our
Congress.
" I have sent your letter to Prof. Lange, who will, no doubt, cor.
roborate my statements. To my knowledge, he has already had similar
questions addressed to him from America, and answered them in the
same way as I have now done.
" The way across is long, the fear of the sea is strong. I do there-
fore firmly believe that it is injurious to the interests of the Congress
to have too many restrictions put for admittance."
The " New Orleans Medical and Surgical Journal " says :
" Since the August issue of the Journal there has been but little
change in the controversy over the organization of the American meet-
ing at Washington in 1887. The disagreement remains as irreconcilable
as ever.
Sept. 12, 1885.]
MISCELLANY.
307
"The situation is certainly without precedent, and all brought about
by the action of a very small majority of a very small meeting of the
American Medical Association, an organization which itself represents
only about one twentieth of the American medical profession. The
association has unjustly been held responsible for the action of scarcely
one fourth of its members, and on this account has suffered severely of
unfriendly criticisms. We trust that these criticisms, instead of im-
pairing the usefulness of the association, will rather enliven the inter-
est of many of the older and more sturdy members whose conservative
presence at the last meeting surely would have averted all our recent
troubles ; very likely the new committee would never have been created.
However, let us speak of the realities.
"No sooner was the new committee organized than it evinced the
temper of the resolution under which they were appointed. They began
to revise, alter, and amend the work of the original committee with a
vengeance. They announced a new plan of organizing the Congress,
based upon an illiberal policy, which, for one reason and another, ex-
cluded from membership on the sub-committees and sections a number
of names of international prominence. There was at once dignified
opposition to the course of the committee, which was all the more de-
termined because of a lack of respect for their authority, owing to the
unpardonable impropriety of the proceedings under which they were
appointed. Numerous resignations from the sub-committees and sec-
tions have followed in rapid succession. So far, upward of one hun-
dred and twenty names, all told, have been either dropped by the com-
mittee or voluntarily withdrawn from all official connection with the
Congress. Many of these names are classical in the history of Ameri-
can medicine, and their disaffection alienates from the coming Con-
gress the friendly interest of our more distinguished confreres abroad,
without whose support the American meeting can not succeed. Our
brethren from over the sea are very emphatic in expressing their views
of the situation. Their criticisms are sharp and well directed. In the
pages of those solid contemporaries, 1 The Medical Press,' the ' Lan-
cet,' and ' The British Medical Journal,' we can see ourselves as others
see us.
"Public professional opinion in the United States demands a truce of
all our domestic differences and the organization of the Congress upon
a broad and liberal basis, recognizing the representatives of American
medicine, those so considered at home and abroad, regardless of all
local code, or purely personal issues, which are so entirely irrelevant to
the purposes of the international body. We say demand advisedly, for
the sixty odd thousand American physicians, in whose name (whether
right or wrong) the invitation was extended and so accepted, as well as
the foreign gentlemen of our own profession, invited to our shores,
surely have some rights entitled to respect.
" If the committee continue much longer in disrespect of those
rights, with as little progress in organizing the Washington meeting,
then the officers of the Congress may see proper, as intimated in some
of our foreign exchanges, to recall acceptance of the American invita-
tion in favor of Berlin, or some other European medical center, where,
as the ' Lancet ' says, ' the medical profession will not find it impossi-
ble to combine for international purposes.' The stigma upon us of
such an occurrence the present generation would not outlive.
" The committee must surely by this time realize the impossibility
of organizing the Congress in further pursuance of their present policy.
As gloomy as the outlook appears, we yet hope that at the coming
meeting of the committee in New York, on the 3d of September, some
way may be found of reconciling all our differences and organizing the
Congress upon a high and broad basis, upon which we can all stand for
the time without jostling and jarring.
" Note. — Since the above went to press, we have received a circular
entitled ' The Pennsylvania Physicians Indorse the Code of Ethics,'
which demands a word from us. The circular is signed by a number
of the ex-presidents of the State and various county medical societies
of Pennsylvania, and others, who indorse the action of the American
Medical Association at New Orleans, as well as the action of the new
committee at Chicago, and call all this sustaining the code of ethics.
This would intimate that those who have not approved of the action of
the American Medical Association or its Chicago committee, on the
subject of the International Medical Congress, do not indorse the code
of ethics of the association. We desire to place ourselves right in
this matter. This journal indorses the code of ethics of the American
Medical Association, but emphatically disapproves of the action of
that body regarding the meeting of the International Medical Congress.
While we support the code of ethics, we do not believe that it was ex-
pedient or right to inject that code into the organization of an Interna-
tional Medical Congress. We believe that the organization of the Con-
gress, as proposed by the original committee, ought to have been
accepted, or at least should have been less radically modified. We do
not take sides with the new-code physicians of New York or elsewhere,
but we sincerely believe that it was inexpedient and unwise to exclude
them solely on account of their ethical sentiments. We are advocates
of the national code, and shall exert our influence to uphold it ; but
we favor no plan of organizing the International Medical Congress
that is not high and broad and liberal, in full accord with the spirit
of the international body, and entirely acceptable to the better sen-
timent of the home profession, as well as to the guests invited to our
shores.
"Under the circumstances, having foreknowledge of the views of
many of our foreign brethren on this subject, we should he more con-
sistent with the principles enunciated by the Chicago committee, under
direction of the American Medical Association, if we should frankly
acknowledge our mistake and withdraw the invitation we have extended.
Either do this or meet them in the spirit they demand."
The " Cincinnati Medical Journal" says:
" It was hoped that the enlarged committee of the American Medi-
cal Association, at its Chicago meeting, would so shape its deliberations
as to escape the imputation of being actuated by sinister motives. The
further we get away from that meeting, however, and the more we
learn of its inside workings, the more are we convinced that personal
pique, local jealousies, sectional prejudices, college hatreds, and clique
antipathies, were more responsible for the changes made than were any
considerations of professional morality or ethical punctilio, or what
should have been first, foremost, and alone, a desire to strengthen the
Congress by bringing to the front our ablest and most representative
men."
The " Chicago Medical Journal and Examiner " says :
" In the organization of the Congress, the same rules should govern
in the next that have obtained in the past. No distinction should be
made between the foreign and the American members. The fact should
be distinctly kept prominent that it is not a delegated body. It has not
been in the past ; there is no valid reason why there should be any
effort to make the next one such. There should not be two or more
classes of members. All must meet on the same plane — with equal
privileges, equal duties, and equal responsibilities. Let all local ethical
questions be eliminated. The foreign representatives expect and de-
mand this, and such is their right. There may be honest differences of
opinion, in our own country, on certain points of principle and policy,
but there can be no valid reason for thrusting them, or their effects,
upon foreigners who may come here. Sight should not be lost of the
fact that science and humanity are the objects for which these con-
gresses convene, and that all matters of selfishness and partisanship
should be subordinated thereto.
" As our faith, as a profession, was pledged, when our invitation
was accepted, to do all in our power to make a success of the Congress,
we can not do less. Everything that might conflict therewith and
diminish the prospect of such success must be kept in abeyance."
The " Maryland Medical Journal " says :
" In view of the fact that the American Medical Association com-
mitted an unjustifiable and unnecessary blunder in authorizing a new
committee to organize the preliminary arrangements for the Ninth In-
ternational Medical Congress, we had hoped that this committee, aft it
the experience of its late meeting at Chicago, would recognize the ab-
surdity of its position and gracefully decline to take further steps look-
ing to an arrangement for the Congress.
" It has seemed to us that the action of this committee has been so
universally condemned, and its resignation so loudly insisted upon by
the almost unanimous voice of the profession, both in this country and
in Europe, that it would not have the boldness to proceed with its work
in face of such outspoken opposition. At first we were disposed to lay
308
MISCELLANY.
[N. Y. Med. Jor.a.
the entire blame for the present muddle of the affairs of the Congress
upon the shoulders of the association. We assumed that this com-
mittee was acting under the instructions of the association, and, there-
fore, in accordance with these instructions, had performed the work
assigned to it in as mild a way as was to be expected under the circum-
stances which had called it into existence. After the utter failure of
its efforts at Chicago, and in view of the disturbance its action has
brought about, we have felt that this committee was in duty bound to
decline any further participation in the work of re-organization of the
Congress. Having so signally failed at Chicago, we are unable to un-
derstand upon what ground it can hope to be more successful in
its future undertakings. From a circular which has recently come into
our possession, we fully recognize the part which this new committee
will attempt to perform. Bracing itself up under the issues of the
' code,' this committee will urge the re-organization of the Congress
upon this platform. It proposes to stand by this issue alone, and to
distribute its loaves and fishes to those only who obligate themselves to
support the national code of ethics.
" We have already shown the absurdity of this issue as applied to
the organization of an International Medical Congress. We must in-
sist that this attempt of the association and of its committee to hoist
this issue into prominence is an insult to the medical profession
throughout the entire world, and an insult to scientific medicine wher-
ever it is taught and practiced. To attempt to enslave individual opin-
ion in this manner is a stab at ethical principles which will penetrate
into the very heart of the national code of ethics and create a prejudice
against these time-honored observances which the association can not
stay. The association and its committee is standing on dangerous
ground, and is inviting a controversy and a strife about medical ethics
which will surely plunge the association into the deepest grief. The
American Medical Association is yet an infant organization. It has
not the power to dictate its terms to the intelligence of the profession
in this country. With a membership of less than three thousand it is
assuming prerogatives and asserting principles which may endanger its
very existence.
" But, after all, this cry of the ' code ' has a tamer significance
than a casual observation would indicate. We have already noticed the
fact that the ' code ' issue has been repudiated by the very best scien-
tific minds in this country and in Europe. The present committee has
caught on to this issue as a possible popular wave to ride into high
official position and authority.
"In our opinion it cares but little for the success of the Con-
gress apart from the popular conception of such an organization. Its
proposition to organize a Congress simply means a jolly good meeting,
with code for breakfast, scientific medicine for lunch, and the Ameri-
can Medical Association for a sumptuous dinner. On this mixed diet
our foreign friends are to be hospitably banqueted, and, if enough for-
eign guests will not come across the waters to partake of this repast,
the jolly feast will be enjoyed all the same by the code adherents and
their friends. Indeed, the whole outlook for the Congress is utterly
ridiculous and absurd. The profession in this country may well cry
shame over its present humiliation. Who can look on and not blush
over such an arrangement as is proposed by our National Medical Asso-
ciation in honor of a great and influential body of scientific workers ?
Who can indorse the work of a committee or accept its proffered hon-
.ors when one has considered the fact that it would gauge scientific
opinion and practice by a standard of conduct which is applicable only
to the most ignorant or unprincipled members of the medical profes-
sion V The empire of science is not bounded by the restrictions of
narrow opinions and prejudices. It demands liberty of action and con-
duct, and it can only make large and enlightened progress when en-
dowed with these functions.
" The effort of our National Medical Association to impose upon a
Congress of scientific men absurd rules of ethical conduct recalls to
mind the narrow prejudices of the middle ages, when men were pun-
ished for asserting that the sun stood still, or that the world was not
made in six days. In the last quarter of the nineteenth century will
the rank and file of the medical profession tolerate such narrow-mind-
edness ? We believe not. This utter absurdity of the association will
surely reach upon its unwise and impious head."
The New York Polyclinic. — We learn that during the sessions of
1885-1886 there will be fifteen clinics in gynaecology each week, in-
cluding operations at Mt. Sinai, Bellevue, St. Elizabeth's, and the Wo-
man's hospitals ; six clinics in the department of diseases of children ;
fourteen surgical clinics, including operations at Mt. Sinai, the German,
and St. Elizabeth's hospitals ; six, each, in diseases of the skin and of
the mind and nervous system ; eight in physical diagnosis, including
ward lessons at Bellevue Hospital ; eight in diseases of the eye, includ-
ing operations at Mt. Sinai and the German hospitals and the Manhat-
tan Eye and Ear Hospital ; four in diseases of the throat and nose ; two
in diseases of the ear ; and four lessons and clinics in obstetrics — mak-
ing a total of seventy-three clinics every week. The laboratory of
pathological histology and State medicine will be open every day and
evening up to ten o'clock, and the laboratory of physiological chemistry
on Tuesdays, Thursdays, and Saturdays. Special attention has been
paid to the outfit for the laboratory, which is fully furnished with all
the necessary apparatus for day and evening work in microscopy, bac-
teriology, chemistry, etc.
THERAPEUTICAL NOTES.
Cocaine in the Treatment of Vaginismus. — Iwow (" Russkaja Medi-
cina " ; " Dtsch. Med.-Ztg.") reports the case of a woman, thirty-two-
years old, who had been married ten years, and had suffered with vagi-
nismus all that time, in spite of every kind of treatment. She was of
slender build, very anaemic, and easily thrown into nervous excitement.
The external genitals were normal, as well as the uterus. The vagina,
was short. Only remnants were found of the hymen. A five-per-cent.
vaseline ointment of cocaine was ordered to be rubbed upon the vulva,
before each coitus. This was late in February, and in April it could
already be ascertained that she was pregnant. In May indisposition to-
coitus supervened, but it yielded to tincture of damiana leaves (twenty
drops every two hours). The author attributes the cure of the vaginis-
mus not to the action of the cocaine alone, but in great measure to the
moral effect of his positive assurance that it would do away with the
pain.
The Choice of Excipients for Topical Applications. — Vigier ("Gaz.
hebd. de med. et de chir.") has written a note on this subject, with spe-
cial reference to vaseline and some of its congeners, such as petreoline,
neutroline, carburine, and petrobaseline, the last-mentioned of which is
the newest of the series and is described as a liquid of fine appearance.
Valuable as these hydrocarbons are, the author deprecates their indis-
criminate use, and summarizes the principles which should guide pre-
scribers in choosing excipients for external applications. Lard and the
oils which resemble it in their action on the skin are the best vehicles
for medicaments. The mineral fats, solid or liquid, although having
the great advantage of being unalterable, offer a certain impediment to-
absorption, retarding it at least. Glycerin prevents absorption, and
should never be used as an excipient, but only for its own effect. On
the contrary, it should be chosen when it is an object to avoid absorp-
tion, as in the use of corrosive sublimate, or to temper the action of
irritants, like carbolic acid or arnica. Petrobaseline seems destined to-
play a prominent part in therapeutics, but its properties, which are cu-
rious in some respects, need to be studied further. It does not dis-
solve boric acid at all, but it dissolves borax. A formula is given for
a four-per-eent. solution, made with the aid of gentle heat and filtered.
The Treatment of Chronic Neurotic Diarrhoea. — J. V. Solomon
("Brit. Med. Jour.") remarks that, in hospital and private practice, he
is sometimes consulted by women of nervous temperament, on account
of a chronic diarrhoea of several years' standing, which has resisted
treatment. When he has failed to discover organic abdominal disease
he has produced considerable mitigation, and sometimes perfect relief,
with the following formula :
Dilute nitric acid \ drachm ;
Battley's liquor opii sedativxis 1
Tincture of gentian Jounce;
Infusion of gentian 4£ ounces ;
Strong peppermint water, enough to make. . 8 "
One ounce to be taken three times a day. He is inclined to consider
the disorder a neurosis.
THE JSTEW YORK MEDICAL JOURNAL, September 19, 1885.
Original Communications.
IMMUNITY FROM CONTAGIOUS DISEASES.
By D. E. SALMON, D. V.M.,
WASHINGTON, D. C.
Although the theory of immunity which I formulated
several years ago has been given a prominent place in recent
discussions, it was not my intention to take any part in this
philosophizing so long as my views were treated with ordinary
consideration and fairness. This theory was not developed
as a mere piece of speculation to while away an idle hour,
nor was its object to excite discussion or controversy. In
the course of a long series of original investigations, in
which very important facts were discovered, I was brought
face to face with this question of immunity, and, in order
to continue the investigations intelligently, it became neces-
sary to have a working hypothesis which explained and
connected the facts so far as known. The theory of immu-
nity in question was the result of that necessity. It was a
sincere endeavor to get at the truth with the facts at hand,
and I only desire that it shall stand or fall on its merits.
The tendency of working scientists has certainly been very
favorable to it ; no facts have been brought forward through
more recent researches which oppose it, while many strongly
confirm it. It does not appear to be so fortunate, however,
when it comes in contact with the arguments of those who
discard tbe facts bearing most directly on the subject, and
reason from questionable premises and comparisons of
doubtful application. A notable example of this may be
seen in the article of Dr. J. Romaine Curtiss which appears
in the issue of the Journal for July 18th.
Dr. Curtiss scores his first point by reversing the terms
of mv theory — a rather remarkable piece of carelessness
when we find him stating it correctly in a quotation from
Dr. Eccles, only a few sentences farther on. " The oxygen
theory of Dr. Salmon," he says, "is too narrow a concep-
tion for the occasion, and there are no verifications to sus-
tain it. Who can imagine that tubercle bacilli in the lungs
can consume the oxygen inhaled so rapidly that there is
not a sufficient supply for the lungs ? The inhalation of
oxygen is found to do harm in consumption as well as many
other diseases. If Dr. Salmon's hypothesis is true, the in-
halation of oxygen ought not only to cure, but prevent all
diseases of zymotic origin." Skipping only one sentence,
we come to Dr. Eccles's very clear statement of my theory
in these words : " The poison of the microbes intoxicates
the cells. Retarded function (of the cells) allows oxygen
to increase in the circulation, thus facilitating their gaining
a foothold. Recovery is due to the ability of the cells to
resist the poison, use up their own oxygen, and so asphyxi-
ate the microbes."
That is to say, of these two contending parties it is no1
the microbes but the cells which injure their antagonists by
exhausting the oxygen supply. Consequently, an artificial
increase of the oxygen supply in the tissues would simply
give the microbes a better chance in their struggle for ex-
istence. The theory here is in accordance with the clinical
fact stated by Dr. Curtiss, and is not opposed to it, as he
would have us believe.
The next objection is that "Dr. Salmon has not made
an estimate relating to the ventilation of the human body
with oxygen and the relative amount consumed by the mi-
crobes and cells." Here again Dr. Curtiss reasons from a
false premise. The most careful chemical investigations
show that the liquids of the interior of the body contain
either no free oxygen or only a trace of it. The cells of
the body which obtain their oxygen from these liquids are,
therefore, able to exist and perform their functions with
this limited supply of oxygen. In other words, the living
protoplasm seems to have such a chemical affinity for this
gas that surrounding liquids are kept practically exhausted.
The very recent investigations of Ehrlich (" Das Sauerstoff-
Bedurfniss des Organismus "), made by a new method aud
apparently incontestable in their results, confirm this view
and place this part of the theory upon a foundation which
a wise man will not attack without mature deliberation.
Equally careful studies of microbes show that their oxygen
requirements are very different, and that some of them re-
quire relatively large quantities of free oxygen in order to
multiply at all. So far, then, as investigations have gone
in this direction, the facts discovered are in accord with my
theory of immunity.
The comparison between a combat in which a dog at-
tempts to kill and eat a man in a well-ventilated room and
the contest of the microbe and the animal cell in the inte-
rior of the body, which Dr. Curtiss next introduces, is one
of the most remarkable arguments which it has been my
fortune to see introduced into the discussion of a scientific
question. It reminds me of the arguments that, only a few
years ago, were hurled by certain members of our medical
profession against the whole germ theory of disease. Not-
withstanding the very positive statement that " the cell and
microbe and man and dog present problems of warfare the
terms of which are parallel and alike," I can not restrain an
equally positive assertion that the comparison is chiefly re-
markable for being far-fetched and having no application to
the question. There is nothing "parallel and alike" either
in the means of attack and resistance or in the conditions
under which the two contests are maintained.
Although Dr. Curtiss thinks that the part of my theory
which admits recovery to be due to the ability of the cell
to resist the poison excreted by the microbe is correct, he
does not appear to be able to free his mind from the belief
that the conttst is, after all, a physical one, and that it con-
sists in the attempt of each to " swallow " the other. That
a free, wandering, or amoeboid cell might easily "swallow"
or take into its interior a microbe, as supposed by Metsehni-
koff, is freely granted ; but that the terms of this proposi-
tion can be reversed, and that a microbe with a smooth,
rounded body, without external organs of any kind, with-
out an opening in its body to take in its food, without the
power of locomotion in the most restricted sense, should
make a physical attack upon and " swallow " a cell, cer-
tainly requires a free use of one's imagination.
310
SALMON: IMMUNITY FROM CONTAGIOUS DISEASES.
[N. Y. Meu. Jonh.,
But why does Dr. Curtiss insist that the combat be-
tween the man and the dog should be in a " well-venti-
lated " room in order to be parallel with a combat between
a microbe and a cell in the interior of the body ? 1 )oes not
the most superficial knowledge of anatomy and physiology
make it apparent that the interior of the body is not well
ventilated, that a contest there, instead of being in the
open air, i ; under liquid, and under a liquid which itself is
not in contact with the air, and from which the cells of the
body are continually drawing the oxygen necessary for their
existence? Then, again, the oxygen requirements of the
man and dog are substantially the same, and any exhaus-
tion of this element would affect each alike. On the other
hand, the oxygen requirements of microbes are very differ-
ent among different species, some of them requiring an
abundant supply, and, as a consequence, a large proportion
of these species must have requirements different from the
cells of the body.
To make the comparison at all parallel and applicable,
it would be necessary to assume that the room in which
the man is located is a close one, that he is able to live in
an atmosphere that would immediately place the dog lwrs
de combat. We must also assume that the dog, even in
this partially asphyxiated condition, continues to live and
exhales a poison which would gradually accumulate and
overcome the man unless its production was so slow that
the man would become inured to it before it had been pro-
duced in sufficient quantities to overpower him. In the
former case we might suppose that the slight ventilation of
the room and the smaller amount of oxygen used by the
man would in time place the dog in a condition to make
an attack. And here, after all our attempts to make the
conditions parallel, we fail miserably, for the dog's attack
must be essentially a physical one, while the microbe's at-
tack partakes but slightly, if at all, of that character.
Of what use, then, is such a comparison for the elucida-
tion of a question of this nature ? Surely any conclusions
drawn from it must be unsafe, misleading, or diametrically
opposed to the truth.
" It is evident," says the learned doctor, " that we can
substitute nitrogen or bile in place of the oxygen of this
problem, and do no violence to the sense or the results."
Here, again, the conclusion seems to be most hasty and
without that consideration which we should expect in dis-
cussing a question of this importance. A moment's thought
would have convinced our able critic that, if the multiplica-
tion of microbes is to be prevented by withdrawing an ele-
ment from the liquid in which they exist, it is a necessary
condition of the case that the element should be one essen-
tial to the growth and multiplication of the germs. As a
matter of fact, neither free nitrogen nor bile is essential to
such growth and multiplication. The germs of various
contagious diseases can be and have been cultivated where
neither nitrogen nor bile exists ; but all microbes that have
been carefully studied and which produce diseases that are
followed by immunity, so far as I have been able to learn,
require a certain amount of free oxygen.
Finally we are told: "Dr. Salmon admits the solution
of the question by natural selection when he says the ' re-
covery is due to the ability of the cells to resist the poison.'
Immunity is also due to the same fact. The oxygen theory
is, therefore, only a rider to the true solution — very much
such a rider, too, as Mazeppa was, in so far as ability to
guide the horse is concerned." If Dr. Curtiss will consent
to lay aside his dogmatic assertions for a moment and con-
sider the, to him, apparently dry and uninteresting facts of
the problem, I may once more be able to show how far
astray even a "philosopher may be led by trusting to a too
superficial glance of a subject. Take the disease known as
fowl cholera for example. The germs of this disease mul-
tiply so rapidly outside of the body that gallons of any nu-
tritious liquid in which a few are placed would be swarm-
ing with them within thirty-six hours. Still, inoculate a
susceptible chicken weighing not over a pound, and it will
be four to six days before the first signs of the disease
appear. In other words, although the germs have found
their way into the nutritive liquids of a susceptible organ-
ism, their multiplication has been checked in a remarkable
manner by the influence of the body protoplasm. If a suf-
ficiently small quantity of the virus is used for the inocula-
tion, the microbes are unable to multiply in the body at
large even after the period of incubation has passed, but
their multiplication is confined to the locality in which they
are introduced. Again, if the number of microbes intro-
duced into the tissues is sufficiently small, say twenty-five
or fifty, there is apparently no multiplication at all ; the
bird does not contract the disease, nor are there any signs
of local irritation, although the cells have never before been
subjected to the influence of the poison, and consequently
have not acquired in that way any ability to resist it. Take
one more fact ; the germs of a contagious disease are un-
able to multiply in the liquids of an animal that has ac-
quired insusceptibility, although they are placed directly
within the blood or lymph channels.
These phenomena are all of the same nature, and they
demonstrate, each in its way, the same fact — viz., that the
protoplasm of the living body has a means of combating
microbes which is not physical, and that it exerts this influ-
ence over the fluid which surrounds it to a considerable dis-
tance beyond the layer that is in actual contact with it.
These facts are evidently very intimately connected
with the question of immunity, and any theory which at-
tempts to explain immunity must not only show how the
cells acquire the power to endure and recover from the
effects of the poison excreted by the microbes, but it must
also explain why the multiplication of these micro-organ-
isms ceases and becomes impossible even in the liquids of
the body and where they are not in actual contact with the
cells. The tissues are, as we know, penetrated by channels
some of which contain blood and others lymph, and there
are everywhere spaces between the cells filled with a nutri-
tive liquid which sustains the life of these minute constitu-
ents of the body. These channels and spaces, compared
with the size of the microbes, are simply enormous, and,
without the part of my theory relating to the oxygen sup-
ply, we can no more understand how the cells (in their
walls) can prevent the multiplication of the microbes in the
liquids flowing between them than we can conceive of the
Sept. 19, 1885.J
ECCLES: DARWINISM AND IMMUNITY.
311
trees on a river's bank preventing the multiplication of the
fish in its waters. There are only two conceivable explana-
tions of the phenomenon ; one is, that the cells excrete
something injurious to the microbes, and the other is, that
the cells withdraw something essential to the microbe's
growth. The former is untenable, because the liquids which
are unsuitable to the microbe's growth when within the
body of the insusceptible animal become very favorable for
its growth when removed from the influence of the living
protoplasm. Evidently, then, they do not contain any in-
jurious principle. Turning to the other explanation, we
must admit for the same reason that whatever is abstracted
by the cells must be something that can be supplied by
contact with the atmosphere. Now, is there any other ele-
ment than oxygen which can be supplied by the atmos-
phere and at the same time is so essential to the multipli-
cation of the microbes ?
From the facts I have mentioned, and from many others
which I have neither the time nor the space to enumerate,
it has seemed to me that when the cells are exercising their
functions in a normal manner, they have such an affinity
for oxygen that this gas is completely removed from the
liquids in the interior of the body ; and, consequently, mi-
crobes which require oxygen can multiply only when suffi-
cient poison is introduced with them, or when they are
present in sufficient number to produce enough poison to
depress the activity of the cells and prevent them from so
completely taking up the oxygen. This theory may be
wrong, but it certainly explains facts which have not been
explained in any other way ; and, if it is to be overthrown,
I presume this will be accomplished by bringing forward
some facts with which it can not be reconciled and by
developing a different theory which, while it explains the
new facts, will not contradict the old ones.
It seems unnecessary for me to answer the charge that
my theory is too narrow, for Dr. Curtiss no sooner makes it
than he sets himself about whittling down even this narrow
theory, and soon asserts that a part of it — the part which
assumes the acquired ability of the cells to resist the poison
— is all that there is to the whole question of immunity.
The inconsistency of this part of his argument is too appar-
ent to need any criticism.
Now a final word as to the utility of the studies of im-
munity, and I hope I shall be permitted to withdraw from
the discussion. I shall not attempt to conceal my astonish-
ment that a professor of hygiene can be found in this coun-
try who deliberately writes that "the study of physically
acquired immunity from disease is interesting only as a
means or end of scientific accomplishment, and is of no
great practical value. . . . Why not destroy the microbe
before it attacks the man, and gain the immunity by this
means ? . . . Immunity from disease gained by costly com-
bat with poisonous microbes is the method of nature with-
out intelligence. The method is not worth imitation ex-
cept provisionally." That is to say, vaccination for the
prevention of small-pox, the method of all others which is
relied upon in every civilized country to hold this disease
in check, " is of no great practical value, and is not worth
imitation except provisionally." How is it, I would like to
ask, that we still rely upon vaccination to prevent small-pox
if it could be so easily combated by destroying the microbe
before it attacked the man ? Why is it that we at the
present day, in the United States, are losing every year
20,000 human lives from scarlet fever, 45,000 from diph-
theria, 14,000 from whooping-cough, 11,000 from measles,
and 120,000 from tuberculosis, and all of these germ dis-
eases ? Is it not because the destruction of the germ before
it attacks the man has been found impracticable and, in the
present state of society, impossible ?
The prevention of small-pox by vaccination has been a
grand and wonderful success — it is the one solitary success-
to which the medical profession can point with pride in its-
long struggle with the indigenous, contagious diseases.
And this we are told is not worth imitation, because it is
the blind method of nature. What is there so terrible in
gaining immunity through actual disease as is practiced on
so large a scale in this same vaccination! And who dare
predict at this time that we shall not, in a few years, have
the virus of the greater part of the contagious diseases so
mitigated that their effects will be as mild as those of vac-
cine lymph ?
There is another possibility even more desirable than
this. We have seen that immunity is acquired by the cells
becoming accustomed to the action of a certain poison ex-
creted by the disease germ. Suppose, as the result of such
studies, the chemist of the future is able to separate this
substance from the germs and supply it, as quinine is now
supplied, in a condition of purity. And suppose, as is very
likely, that the introduction of this substance into the tis-
sues would confer as complete an immunity as occurs when
it is produced there by the germs, would this not be a solu-
tion of the question worthy of many years' investigation ?
Until we succeed better than we have in the past in
destroying the germ before it attacks the man, let us not
insist upon this method to the exclusion of all others, at
least so long as over two hundred thousand of our popula-
tion annually testify by the sacrifice of their lives to the
inefficiency of this method.
DARWINISM AND IMMUNITY.
By B. G. ECCLES, M. D.,
BROOKLYN.
Broad generalizations are excellent. They co-ordinate
a host of facts in a general way. To rest satisfied with
such a mere outline is essentially unscientific. It is a de-
plorable fact that many intelligent people use them to jug-
gle with. They seem to imagine that everything is settled
when it is found that some magic formula does not disagree
with the facts. They may dimly see, but fail to appreciate,
the truth that within every general hypothesis many par-
ticular ones must be held. Waves of ether can in a gen-
eral way explain the phenomena of light, but, when diffrac-
tion requires explanation, we must supplement it with
eurvinga around a sharp edge and interference. The theory
of natural selection has, by the consensus of the competent,
been pronounced tenable. We need not on this account,
dazzle our mental vision with its luster until unable to de-
312
EC CLE 8: DARWINISM AND IMMUNITY.
[N. Y. Med. Joi k.,
tect its minute interactions in particular cases. To say that
natural selection is an essential factor in the acquisition of
immunity from disease is only to utter a truism. Immu-
nity, in its broad sense, is clearly due to the survival of
such animals as have acquired some power of resistance
against disease. In stating this we explain nothing more
than is usually perceived by all medical men. Our entire
period of life is only possible because of the accumulated
gifts of heredity. The power to adjust every part in a
manner favorable to the resistance of antagonistic forces
constitutes the totality of physical life. In gaining a new
readjustment against disease, our cells do nothing more
than all cells appear to have been doing since the very
beginning of life upon this planet. Variation has been
going on incessantly and in all conceivable directions. The
conserving force of heredity, with its strange and occasion-
ally acting form of atavism, has preserved these wonder-
ful powers of immunity we now possess. When, however,
we wish to explain particular cases of the subtle interac-
tions of variation and retention, new facts and new hypothe-
ses are involved. The mere fact of immunity is no longer
the only thing we require light upon.
In the "New York Medical Journal" for July 11th and
18th Prof. Curtiss advances as his the general theory of
selection as applied to immunity. It is a true theory, but
very incomplete, and entirely too elastic to suit particular
cases. There can be little doubt of its having been enter-
tained by Dr. Salmon before he supplemented it with his
own. In fact, they are parts of one another. The most
general part being inadequate required the particular addi-
tion to explain particular cases. While the general law
covered the fact of immunity, it gave no hint as to why
one disease was self-limited and another was not. Why do
the pathogenic microbes of measles soon die out, while
those of tuberculosis remain for many years to multiply,
and finally destroy the patient ? There must be some rea-
son for the rapid adaptation in one instance and its slow
appearance, or perhaps non-adaptation, in the other. To
this question the general theory has no reply. The par-
ticular one explains it lucidly. Why does one attack of
small-pox give greater immunity than ten attacks of inter-
mittent fever? Why does cultivation of pathogenic mi-
crobes in limited supplies of free oxygen make them more
virulent ? Why do harmless bacteria become dangerous
disease-breeders when so cultivated ? Why does cultivation
of anthrax in large supplies of air, as accomplished by
Pasteur, render it so mild that it can be used for inocula-
tion, and, when carried far enough, make it harmless ?
Salmon's theory has a rational explanation of all these and
many more facts which the general theory can only ignore.
The weakest link in the whole chain of Dr. Salmon's theory
is the one commended by Prof. Curtiss. The strongest one
he rejects. Every experiment so far tried has utterly failed
to verify the assumption that the method of warfare of
pathogenic microbes is by poison, and that immunity comes
from resistance by the cells to this poison. If this point
could be established the hypothesis would be demonstrated.
It can only be verified by experiments upon the cells. Prof.
< Jurtiss tells us that this is the only truth in Salmon's theo-
ry. Dr. Salmon would certainly be rejoiced if Prof. Curtiss
would give him the proof of its truth. He has waited
and worked nobly for years trying to get this proof, but,
alas ! it does not yet appear. The oxygen part of the
theory for which the professor shows so much contempt is
based upon the nature of the microbes, so that its substan-
tiation is as perfect as it possibly can be until it is verified
as a whole. Aerobic microbes become pathogenic when
modified by submersion into amphibious. This is the full
extent of modification to which they have been proved sus-
ceptible. Prof. Curtiss tells us that Bacillus sublilis has
been transmuted into Bacillus anthracis. He therefore in-
dorses Buchner's idea, which is rejected totally by all bac-
teriologists. It has been proved that when Buchner was
at work trying to accomplish this miracle his room was
full of B. anthracis spores, and that, bis alkaline solutions
being their natural medium, they necessarily had a sowing
and growth. The B. subtilis which he planted, being only
capable of development in acid solutions, perished. The
common morphological appearance of the two species de-
ceived him. No one has ever been able to do it in a non-
infected room. Prof. Curtiss is unfortunate in indorsing
unsubstantiated positions.
Given such micro-organisms as can barely live in the
quantity of oxygen supplied by our blood, and without
some toxic principle by which to damage the cells they
would be harmless. Given now a deadening ptomaine to
arrest cellular function, and the air-supply will at once in-
crease. Experiment has shown that harmless bacteria be-
come pathogenic when introduced with a heavy physiologi-
cal dose of atropine. Experiment has also shown that such
bacteria perish unless the solutions containing them are
well aerated. With such organisms and their poisonous
ptomaine, their rapid multiplication will soon overwhelm the
cells. We shall have disease. Now given a modification
to the cell by virtue of which it can resist the paralyzing
action of the ptomaine, function will be re-established,
oxygen consumed, and the already half-choked microbes
perish rapidly. The life-history of such microbes, under
the given conditions, runs exactly parallel with the inva-
sion, incubation, and self-limitation of sucli diseases as
measles, scarlet fever, and small-pox. Such microbes re-
quire more air than the cells, since the cells meet their ex-
act adaptation to the work of the skin and lungs. But
there is known to be another class of microbes which Pas-
teur calls anaerobic. They can live on even less free oxygen
than cells. These, according to Dr. Salmon, cause an en-
tirely different class of diseases. The general theory cham-
pioned by Prof. Curtiss can make no such distinction. It
explains all alike, and, according to it, there should be no
such difference in diseases. In intermittent and remittent
fevers, tuberculosis, etc., there is no such self-limitation nor
following immunity. Why ? In malaria the system is over-
come by the poison and the microbes, but fails to gain im-
munity. Rally as it will, it can not expel its foes. Their
power of absorbing oxygen is too great to ever be damaged
by the restored function of the cells. Tubercle spreads in
spite of any limitation of oxygen. It can steal from cell-
tissue if not secured from the blood. The facts of the dis
Sept. 19, 1885.]
ECCLES: DARWINISM AND IMMUNITY.
3L3
ease and the facts of microbic nature agree precisely. Dr.
Salmon points, out this agreement. Immunity to anaero-
bic microbes can only come after generations of selection,
if at all. Immunity to aerobic or amphibious results from
personal experience. No other hypothesis tells wherein
these broadly contrasted classes differ.
Prof. Curtiss says that, according to Dr. Salmon's the-
ory, " the inhalation of oxygen ought to not only cure, but
prevent all diseases of zymotic origin." The professor
seems to be as unfortunate in the inferences he makes as in
the proofs he cites. The very reverse of what he says must
be true. To supply more oxygen is to save the microbes
from asphyxiation and add to their ability for ill. How he
drew a reverse conclusion from the words he quotes is cer-
tainly a mystery. Facts support the true implication as he
has pointed out. To say that " it is evident that we can
substitute nitrogen or bile in place of oxygen " is to talk
nonsense. Do microbes perish for lack of free nitrogen or
bile ? Does cultivation of them in limited supplies of nitro-
gen or bile make them more virulent ? Is free nitrogen or
bile a life necessity for them and cells? Would their ex-
creted poison arrest the absorption by all cells of nitrogen
or bile ?
The man and dog illustration is anything but apt. Al-
most every condition is subverted. Had he put man and
dog into a diving-bell, with a pump supplying barely
enough air for the man, the cases would have been nearer
parallel. Let the man now use up all the oxygen from the
dog. The gasping animal, by grasping for his trachea, will
succeed in securing a supply for itself. As soon, however,
as the man frees himself from the dog, the latter must die.
With the case so stated, the oxygen theory becomes much
more than a Mazcppa rider. If the professor thinks that
the surplus of oxygen is as large in the blood for the num-
ber of cells it sustains as it would be in a well-ventilated
room for only a man and dog, perhaps he will not object to
close the ventilation of his body and see whether it will last
as long as that of a room containing a man and so closed.
The inhibition of cellular function is the inhibition of oxi-
dation. Will the professor kindly inform us if it likewise
is the inhibition of nitrification, or of the absorption of bile
in the same extensive manner?
Innovations that oppose established custom are usually
considered bad affairs. The promulgators are pronounced
absurd and illogical. On the whole, this is right. The
vast majority of proposed innovations are but the chatter-
ings of cranks. The conservative instincts of men socially
represent the biological law of heredity. Innovations are
but variations. For every useful variation there are proba-
bly millions of useless or even mischievous ones. Conserva-
tism does a good work in challenging all, and only surren-
dering when the last credential is presented and understood.
He who proposes an innovation is unmanly if he dares not
defend it when called to the task. It is not pleasant to
stand amid an army of semi-lunatics and be classed with
them. One's only consolation lies in the fact that extremes
are all alike. The ultra-violet rays of the spectrum are as
dark to our blind eyes as real darkness. A man with clear
ideas beyond his fellows seems the same to them as the fool
or lunatic, whose utterances he knows are folly. But even
the brightest thinkers have erred, so that it is the part of
wisdom to challenge everything new. To assert that in-
oculation or vaccination after exposure to small-pox is a
dangerous proceeding is to fly in the face of established
custom and wage war with conservatism. There are two
theories now in the field regarding this point. The first
asserts that, so far from being dangerous, it will mitigate
or altogether prevent an attack. This theory, like the
geocentric one in astronomy, has the sanction of age and
customary belief. The fathers taught it, and the sons must
believe it. Its genesis can be traced to the bastard general-
ization, similia similibus curantur. It offers no other
rational explanation for its existence. Its anomalies are as
mysterious as the sphynx. The little sound experimental
knowledge we possess seems to negative it. Its defenders
appear to be as utterly oblivious of what constitutes valid
proof as religious zealots in an experience meeting. It
offers no scientific proof of any kind. The same custom,
to which it is indebted for its very being, forbids our at-
tempting to either prove or disprove it in the only way it
can ever be satisfactorily done. By human vivisection we
must discover the power of resistance of those we propose
to use for proof. By the same we must learn to measure
our doses of virus. With a standardized virus and stand-
ardized patient we can prove or disprove the point. With-
out these we are totally at sea. Accidental inhibitions of
virus can never give sound premises upon which to reason.
If we could measure our doses of small-pox virus and dis-
cover just how much a patient could stand without taking
the disease, the matter would soon be settled. If, after
taking a given quantity of standard virus, a number of per-
sons with a common resistance were divided into two
parties, the one vaccinated and the other not, and while
the former escaped the latter took the disease, the case
would be clear. But where can we find such proof? In-
stead of it, a lot of ill assorted and little understood personal
experiences is cited. Every so-called fact must be supple-
mented by an assumption fatal to even an approach to accu-
racy. They must assume that the person had never before
been vaccinated. They must assume that he had no extra
supply of resistance, and would have taken the disease or
been worse with it, but for vaccination. They must assume
that he imbibed just enough of the virus to produce certain
results. In fact, every important point must be assumed
to suit the fancy of the reasoner. What wonder that the
conclusions are always just such as are wanted? Even if we
had results from large bodies of men like soldiers to reason
from, the law of general probabilities would avail but little.
Our data would be so very insecure, scarcely anything could
be made out. Proof, therefore, from human experience, of
the truth of either theory is utterly valueless, and it is but
a waste of effort to cite it. Our only available proof must
be derived from general principles and from experience
among animals with analogous diseases. The second theory
is opposed to the one given, and declares that vaccination
after exposure to small-pox assures to some of those so ex-
posed and vaccinated an attack of the disease which they
would have escaped but for the vaccination. It also asserts
314
MACKENZIE: INFLAMMATION OF THE AIR-PASSAGES. [N. Y. Med. Jo™.,
that such as have imbibed a minimum amount of the virus be-
fore vaccination will suffer more than by being vaccinated at
another time. So far as experimental proof on human be-
ings is concerned, this theory is as baseless as the first. So
far as any proof is concerned, they are both merely guesses
of great or little probability. Experiments upon domestic ani-
mals have, in the hands of several investigators, shown the last
theory to be true, at least for animals in their diseases. This
proof is the same in kind as that upon which we accept the
germ theory of disease. We are not allowed to prove either
upon men. Even condemned criminals, who, by their death,
might do that good to humanity they failed to do w hen
alive, are wasted upon the gallows. If Salmon's theory of
immunity is true, this vaccination theory is likewise true.
The latter is implied by the former. Even the more gen-
eral theory accepted by Prof. Curtiss appears to imply it.
There can be no curative power in the virus of either kine-
pox or small-pox. To believe otherwise is to believe homoe-
opathy. The latter insures protection to the former, not
because they antagonize one another, but for a reverse rea-
son. Meeting the one teaches how to resist the other, be-
cause of likeness. They vary only in degree of strength,
not in quality or mode. Such is positively known to be the
case with all artificially prepared viruses of charbon, chicken
cholera, hog cholera, and hydrophobia. Kine-pox is but a
weak or sickly form of small-pox, as experiment has shown,
and as the history of the former, so far as known, seems to
confirm. A short period of incubation, in inoculation, ap-
pears, from Pasteur, Salmon, Detmar, and Law's experi-
ments, to be due to its local character. A tenth of a milli-
gramme of microbes or less will not take as long to develop
and fill a local sore as ten or more milligrammes to infect the
whole body. Vaccination produces a local sore in which
the microbes are confined. The ptomaines osmose through
into the blood, producing the constitutional symptoms and
weakening the vital resistance of the cells. With weakened
vital resistance, even according to Prof. Curtiss's natural-
selection theory, the microbes should have more favorable
conditions for rapid multiplication. The period of incu-
bation is only the period of microbic multiplication by fis-
sion. How, then, can immediate vaccination mitigate or
destroy a threatened attack of small-pox ? Wherein does a
shorter period of incubation of the former make it give
protection to the latter ? Its short period can only shorten
the period of the latter and hurry up the attack. They are
not bane and antidote, as Prof. Curtiss assumes. They are
either identical or synergistic poisons, and in no respect
comparable to atropine and morphine. They have no an-
tagonisms. At least, none have ever been proved. They
aid each other, not because of antagonisms, but because of
identities. The cells learn to antagonize both from one,
because of their features of identity. When Prof. Curtiss
asserts such antagonisms between them, he gives up his
natural-selection theory of immunity. He says : " Their
antagonisms may depend upon the priority of their invasion
of tissues." We have not one particle of proof that they
have any antagonism. He merely assumes such. He for-
gets, too, when trying to give a reason for this imaginary
antagonism, that the small-pox virus enters first and the vac-
cine virus last. The long period overlaps the short one so
that their terminations may coincide, and they fortify one
another with all their might. If such antagonism was a
fact, the period could not possibly have anything to do with
it, as is here seen. It must be radically lodged in the
viruses. But bow will he explain Pasteur's virus, Salmon's
virus, and the many other artificially prepared viruses where
we positively know there can be no antagonism ? If the
viruses are radically antagonistic, we can have no immunity
from them by any acquired antagonism of the cells. The
tobacco habit gives no immunity in the use of arsenic or
strychnine. Either Prof. Curtiss must give up his theory of
immunity by natural selection or his theory of antagonism
between the viruses of kine-pox and small-pox. They are
thoroughly incompatible and mutually destructive. His
Socratic and Durham arguments are funny but not to the
point. Does he not take a little too much license in using
atavism (L. avus, a grandfather) as synonymous with he-
redity (L. keres, heir) ?
REFLECTIONS ON THE AETIOLOGY OF THE
SIMPLE INFLAMMATORY AFFECTIONS
OF THE UPPER AIR-PASSAGES.
By JOHN N. MACKENZIE, M. D.,
BALTIMORE.
(Concluded from page 290.)
Besides being predisposed to or conditioned by patho-
logical states of the system as a whole, catarrhal affections
of the nose and larynx are not infrequently the result of re-
flected irritation from its individual parts, as, for example,
disease, over-stimulation, or suppression of the functions of
the cutaneous (eruptions, suppression of perspiration, etc.),
gastro-intestinal (habitual constipation, haemorrhoids, para-
sites, etc.), or genito-urinary apparatus (Bright's disease,
utero-ovarian irritation, etc.), teeth and gums (caries, den-
tition, etc.), external auditory meatus or middle ear (inflam-
mation, impacted cerumen, parasites, etc.). Let us examine
this subject more closely : As the respiratory passages and
skin are the sole avenues through which oxygen reaches
the blood, and as they are held in close consent by virtue
of their community of function, it naturally follows that
the abrogated activity of the one will necessitate vicarious
action on the part of the other. This supplementary or
compensative action, if prolonged, sooner or later trans-
cends its physiological limits and eventuates in morbid con-
ditions of the organs whose machinery has been thereby
overtaxed. Familiar examples of this vicarious action are
the congestion or inflammatory disorders of the respiratory
apparatus which follow sudden or prolonged interference
with the cutaneous functions, as in sudden chilling of the
external surfaces or in the exanthemata, the sudden sup-
pression of tinea capitis and eczema, and, on the other
hand, the night-sweats of consumption. One word in re-
gard to the eruptive fevers. The catarrhal naso-laryngeal
disease may usher in the attack (especially is this the case
in measles), may occur coincidently with the exanthem, or
may follow the disappearance of the latter, or, finally, it
may not develop until convalescence has begun. The ca-
tarrhal affections complicating the essential fevers may dis-
Sept. 19, 1885. j
MACKENZIE: INFLAMMATION OF THE AIR-PASSAOES.
315
appear completely during the latter period, but in many
cases go on to the chronic state. This is especially true, in
my experience, in regard to affections of the naso-pharyn-
gcal space. There seems to be a special tendency to the
localization of the disease in this region, and a large major-
ity of the cases of hyperplastic conditions of the adenoid
tissue coming under my observation, are directly traceable
to some acute blood-poisoning in infancy, as scarlet fever,
measles, diphtheria, etc. This is doubtless due, to a great
extent, to the fact that the naso-pharyngval affection is
overlooked by the attendant ; but it may be that the ten-
dency of the eruptive fevers to leave traces of their existence
in the glandular structures of the throat (notably the ton-
sils) may determine diseased conditions of the adenoid ele-
ments of the nasal pharynx.
It now and then happens that during convalescence from
acute infectious processes irregular fluctuations in the tem-
perature occur, and even a veritable septicaemic condition,
inexplicable by the ordinary examination of the functions
of the patient, and which depend upon the persistence of
the inflammatory process in the retro-nasal space. I have
observed this after scarlet fever and diphtheria, but there
is no reason why it should not occur in other and allied
affections. This is an important practical point, for by
simplv cleansing the naso-pharynx of decomposing secretion
(I find bichloride of mercury to be the best agent for this
purpose) the temperature becomes normal and the disa-
greeable symptoms dissipated. In this connection let me
observe that in all infectious processes characterized by in-
flammatory manifestations in the pharynx the greatest relief
to the child may be secured through careful cleansing of
the retro-nasal cavities. In diphtheria, for example, the
greatest comfort is experienced by attention to this expedient.
To digress still further : In the ordinary acute catarrhal
throat affections of infancy much comfort may be given,
and the tendency to spasm diminished, by careful attention
to the nasal and retro-nasal cavities.* There is an old
woman's saying in this part of the country that " if a croupy
child sneezes, it is well." But no one ever thinks of the
nasal passages in connection with a croupy infant. Yet there
is, nevertheless, always more or less inflammation of the
post-nasal passages, and the tendency to spasm may be
diminished by cleansing the passages of mucus, especially
before the child retires for the night, f
There is an affection of the skin which is observed in
connection with certain forms of coryza, and notably that
of sympathetic origin, or rhinitis sympathetica. I refer to
urticaria. It appears and subsides with the coryza, and
seemingly depends upon the imperfectly defined neurosis
or vaso-motor influence which is probably the connecting
* In this disease, too, the paralytic condition of the palatal mus-
cles interferes materially with the voluntary removal of secretion from
the retro-nasal space.
f The influence of the febrile state is also occasionally exerted in the
direction of cure of existing catarrhal disease, of the nasal passages and
throat. This is especially true of those affections with special ten-
dency to local manifestation in the throat, and the cure may be perma-
nent or temporary. I have also observed complete disappearance of a
naso-pharyngeal catarrh during the course of malarial fever. (See
paper read before this association at its last session.)
link between the two affections (possibly some functional
derangement of the cervical sympathetic).
Passing now to the reciprocal relationship existing be-
tween the turbinated nasal tissue and the auditory meatus
and middle ear, it is not an uncommon matter in my expe-
rience to find that the subjects of chronic nasal inflamma-
tion suffer from a more or less constant dryness and itching
of the former or a tendency to the inspissation of cerumen,
and this, apart from existing disease of the middle ear. I
have on several occasions adverted to the role of congestive
conditions of the erectile tissue in the production of mid-
dle-ear affections (doubtless through reflex influence). It
remains for me to call your attention to the fact that uni-
lateral coryza, either acute or chronic, sometimes depends
upon irritation of the external auditory passage. Two
years ago I was consulted concerning a case in which a se-
vere unilateral discharge, with stoppage of the nostril, hemi-
crania, and other phenomena referable to the same side, of
a number of weeks' duration, was completely dissipated by
the removal of a mass of impacted cerumen from the ear
of the affected side ; and recently a similar case has come
under my professional care in which the swelling of the
erectile tissue disappeared upon removal of the ceruminous
plug. In the presence of these facts the conclusion is irre-
sistible that an intimate physiological relationship exists
between the nasal cavities and the auditory meatus.*
It has thus been shown that nasal and laryngeal inflam-
mation may proceed from the direct or indirect (reflex) irri-
tation of a host of substances derived from the external world,
from an almost indefinite number of pathological conditions
of the system as a whole, or from irritation or disease of organs
distant from the seat of local inflammation. The predis-
posing influence of certain structural peculiarities of the
nasal chambers remains to be briefly adverted to. These
consist most commonly in deflection (or malposition) and
perforation of the septum, anomalous conditions of the tur-
binated bones (hypertrophy, abnormal position, atrophy?),
and disturbance of the anatomical relations of the nasal
fossae either through accident or disease. There are certain
anomalies of structure of the throat and nasal passages that
are seen in several members of the same family which are
undoubtedly inherited and which are of such a nature as to
give rise to no inconvenience, or, on the other hand, en-
courage the development of inflammatory processes; in the
latter cases their influence is purely mechanical. There also
exists in some families & peculiar vulnerability of the m ucous
membrane of the nose and throat which is sometimes con-
spicuous for several generations. Such persons arc said to
" inherit" catarrhal inflammation or to be the subjects of
the " catarrhal diathesis " — a view which has descended to
us chiefly from the earlier French physicians. It is uu-
* In certain persons, notably those of highly developed nervous
organization, or in the hysterical or hypochondriacal, coryza is occasion-
ally produced by direct impression upon the olfactory nerve, or, from
simple association of ideas, by physical or mental over-exertion or emo-
tional excitement. Here there is usually some co-existing local nasal
disease or vaso-motor neurosis, and such cases are closelv allied to, if
not a part ami parcel of, the sympathetic form of rhinitis (rhinitis sym-
pathetica). (See abstract, in "Maryland Medical Journal1," April 11,
1885, of paper read before the Clinical Society.)
316
'doubtedly true that the children of parents debilitated by
disease, excesses, or other causes, or who inherit, for exam-
ple, the enfeebled constitution of the syphilitic or tuber-
cular, diatheses well known as predisponents to catarrh,
may, by virtue of the inheritance of a vice of constitution,
yield more easily than those of healthy parentage when ex-
posed to the exciting causes of the disease ; but there is no
evidence yet adduced that puts beyond a reasonable doubt
the descent of a simple inflammation from father to son.
These remarks apply with equal force to the so-called ca-
tarrhal diathesis, which latter may be looked upon simply
as a generic term for a multitude of varied physical pecu-
liarities, each susceptible, upon close analysis, of reference to
a definite and tangible cause, or to a combination of inju-
rious influences.
Catarrhal inflammations of the nose and throat in the
newly born, when not due to gonorrhosal inoculation, proba-
bly owe their origin to causes operating during iutra-uterine
life* It occasionally happens that inflammatory affections
of these cavities are ushered in at some physiological epoch,
as puberty, or existing disease dissipated by the nutritive
changes which occur at that period. The subacute laryn-
gitis which occurs at puberty occasionally develops into a
chronic inflammation, especially in the subjects of inherited
constitutional vices — a fact which it is well to bear in mind
both in a prophylactic and prognostic point of view. In-
flammatorv conditions of the throat and nasal passages occa-
sionally make their appearance at the menstrual period, ap-
pearing either coincidently with the uterine haemorrhage
or as the vicarious representative of that process, and I have
seen one case where a catarrhal affection of these passages
ushered in the menopause and subsided with the termina-
tion of menstrual life.f
Etiology of Pharyngeal and Laryngeal Inflammation.
— The chief predisposing causes of acute pharyngo-laryngeal
inflammation are the existence of chronic hyperemia or in-
flammation of the naso-bronchial tract, abnormal state of
vitality from inherited or acquired disease, excesses, subjec-
tion to imperfect sanitary conditions, and constant confine-
ment to a vitiated atmosphere. While in the vast majority
of instances acute inflammation of the pharynx or larynx
occurs as a complication of acute or chronic naso-pharyngeal
(or bronchial) catarrh, it may nevertheless be met with as a
primary affection. I do not share the extreme view of my
friend Dr. Bosworth, who has written so well upon this sub-
ject, that acute laryngitis only occurs as a symptom of the
chronic form. While I regard the existence of the latter as
its most prominent predisposing cause, it is nevertheless
true that the disease may appear as a primary affection lim-
ited to the laryngeal or pharyngeal structures.
Apart, then, from the inflammation resulting from local
pathological processes, mechanical or chemical injury, abuse
of the forces of expiration and inspiration, the isolation of
* See article by the author in " Phila. Medical News," October 4,
1884.
■f- See on this subject a paper by the author on " Irritation of the
Sexual Apparatus as an ^Etiological Factor in the Production of Nasal
Disease," "Am. Jour, of the Med. Sci.," April, 1884. (Prize essay,
Maryland Academy of Medicine.) I
|N. Y. Med. Jodr.,
this disease in the larynx (acute primary laryngitis) is one
of the rarest of pathological events. In adult and infant
it most commonly occurs as a complication of acute nasal
catarrh or as a part of a general inflammatory condition of
the naso-bronchial tract. I am inclined to believe that in
the irritable state of the nasal tissues, and notably the
cavernous bodies, resides an important etiological factor
in the adductor spasm which characterizes the disease in
the infant ; the engorgement of the sensitive area when the
recumbent posture is assumed, and the gravitation of the
nasal secretions into the laryngeal vestibule, being the most
important agents in awakening the reflex laryngeal spasm.
In the adult, acute catarrh of the larynx is a relatively rare
disease, a fact which is remarkable, as Flint* has pointed
out, in view of the frequency of acute pharyngeal inflamma-
tion, and illustrates the conservatism of the natural law in
regard to the extension of inflammation.
The reflex or collateral hyperamia of the larynx which
is present in inflammatory conditions of the nasal and pha-
ryngeal cavities is too often mistaken for acute inflamma-
tion, and confusion too often arises, especially when the
laryngoscope is not available, from failure to remember the
simple truth that hoarseness is not laryngitis.
Chronic catarrhal laryngitis as an isolated affection is
rarely met with ; it is almost invariably secondary and as-
sociated with inflammatory disease of the nose or nasal
pharynx, upon which it, in the large majority of cases,
depends. Indeed, setting aside the inflammation which re-
sults from purely local irritation, it may be laid down as a
law that the vast majority of cases of catarrhal, pharyngea ,
and laryngeal disease originate primarily in inflammation of
the nasal cavities. Catarrhal rhinitis leads to inflammation
of the pharynx and larynx in one or all of the following
ways:
1. By mouth breathing, which I may say acts not only
through the irritation of the cold, dry, and impure air in-
spired through the mouth, as in nasal obstruction, or through
the nasal passages, as in atrophy of the turbinated struc-
tures, but also by crippling the respiratory and vocal
forces, shortening both inspiration and expiration, com-
pelling rapid respiration and resulting vocal and respiratory
fatigue.
2. By the constant endeavor to overcome the loss of
nasal power and resonance, and the consequent pharyngeal
and laryngeal fatigue.
3. In certain cases, by interference with the normal mo-
tility of the palatal structures.
4. Through reflected irritation.
5. By the irritation of the atmosphere, vitiated in some
instances, not by virtue of its passage through the mouth,
but through the nasal chambers themselves.
6. ByT so-calied extension of inflammation.
7. Possibly by irritation of secretion.
In studying the pathological conditions of the naso-
pharyngeal space and middle ear, we may, for practical
purposes, regard these cavities as accessory to the nasal
chambers, so intimately interwoven is their pathology with
a diseased condition of the nasal fossae. As stated else-
* " Principles and Practice of Medicine," Philadelphia, 1873, p. 263.
MACKENZIE: INFLAMMATION OF THE AIR-PASSAGES.
Sept. 19, 1RH5.|
CORNING: EXPERIMENTS WITH COCAINE.
317
where,* iu a large proportion of cases of so-called middle-
ear inflammation the latter " is merely a symptom of nasal
catarrh, and gradually disappears without special treatment
upon the removal of its primary cause." When the middle-
ear affection is thus symptomatic, it is generally traceable
to mechanical causes or to reflected irritation.
Inflammatory conditions of the naso-pharyngeal cavities
are encouraged and existing disease of these structures per-
petuated by paralytic conditions or defective muscular power
(e. from existing chronic inflammation, enlarged tonsils,
defective innervation, etc.), or from abnormal approxima-
tions of their walls (from adhesions). As a consequence of
the impaired functional exercise of the structures thereby
induced, congestive and catarrhal processes develop in the
laryngeal cavity, which result from the constant endeavor
by abuse of the expiratory forces to overcome the loss of
power in the pharynx. Both loss of power and adhesions,
which latter act by crippling the muscular action and disturb-
ing normal anatomical relations, tend also to prevent volun-
tary cleansing of the retro-nasal space, and thus form an-
other factor in the persistence of the chronic inflammatory
process.
Finally, I wish to observe that in a large proportion of
cases it will be found, upon careful examination, that the
existence of the nasal, pharyngeal, or laryngeal affection is
not due to any one particular cause, but to a combination
of injurious influences — the resultant of a number of inter-
nal and external forces.
DISCUSSION.
Dr. J. Solis-Cohen : We gather from the essay the fact, not
fully appreciated, that many catarrhal affections are due to cli-
matic and constitutional conditions, and that this indicates a
feature in the treatment which is too trequently ignored. Cli-
matic conditions can not be altered, but the susceptible indi-
vidual can be protected by suitable hygienic and dietetic super-
vision. The function of digestion and the secretions of the
intestines and kidneys must be attended to, the skin be kept in
good order, and thus revulsive measures be adopted to with-
draw morbid influences from the upper respiratory tract. Too
great an attention to local measures without due consideration
to constitutional conditions does not fulfill the requirements.
Acute laryngitis, in my experience, occurs frequently in in-
dividuals who are not at all suffering with chronic catarrhal
disease, and subsides without such a sequel. On the other hand,
subacute inflammations occur most frequently, in my experience,
in the subjects of chronic disease as exacerbations due to some
special exposure.
The spasmodic affections of infants alluded to in the paper
as occurring in the subjects of chronic naso pharyngeal catarrh
are similar in origin to the night-cough of infants, being due to
trickling of mucus into the larynx. The indication, then, is to
place the sleeping infant in a position which will not favor the
entrance of secretions into the larynx, and, of course, to treat
the catarrhal disease.
Dr. H. A. JonNSON: Naso-pharyngeal catarrh is common
around our lakes, and is frequently benefited by a change of
climate to the Western plains, up to an altitude of five thousand
or six thousand feet. In the high mountains the disease is ag-
gravated. In the treatment of this trouble tonics are usually
* "Trans, of the Med.-Chir. Fac. of Maryland," 1883.
of great value, and we are tempted to overlook the general con-
ditions in the presence of the local lesion.
Dr. Glasgow : I can not strictly agree with the speaker in
the relative importance of atmospheric change and dust in pro-
ducing catarrhal diseases. Although rapid changes of atmos-
phere lead to catarrhal disease, I fully believe that dust or atmos-
pheric dirt holds the most important place in their production.
We find evidence of this in the fact that people living in atmos-
pheres laden with dust are particularly liable to catarrh. For
instance, persons living in my own city — St. Louis — are espe-
cially prone to these troubles. Removal into the purer air of
the country invariably lessens the difficulty, and it is again ag-
gravated by a return to the city. I believe this is the general
experience in all dust-laden cities.
We also see evidence of the importance of dust in the expe-
rience of people in the alkali regions of the West, and this with-
out special regard to the elevation. Catarrhal disease is the
rule in this section. If previously existing, it is aggravated ; if
the naso-pharyngeal membrane was previously healthy, a com-
mencing catarrhal inflammation is soon noticed.
Dr. Ingals : I agree with the other speakers as to the ne-
cessity for attending to the constitutional condition of the pa-
tient, but we must not lose sight of the constitutional manifes-
tations due to the nasal disease. In many cases great impair-
ment of the general health, which may have existed for years,
is dependent upon nasal obstruction, and remarkable improve-
ment will immediately succeed removal of the nasal affection.
Dr. Allen: The study of catarrh should be considered in
great part as a phase of morphology. The careful study of
each separate ca<e is important. It is always well to treat indi-
viduals rather than diseases. The identification of the local
structural cause of the catarrh is, in the majority of instances,
alone possible after unremitting scrutiny.
Dr. Mackenzie: I fully agree with Dr. Allen as to the im-
portance of local treatment; at the same time it should not be
forgotten that in many instances the balance between cure and
failure may be easily turned by neglect of constitutional meas-
ures. Cases occur in which local measures must be carried out
before relief can be obtained, while, on the other hand, consti-
tutional measures must be employed in order to secure the
maximum of good in treatment. Dr. Glasgow misunderstands
the position which I took in regard to dust as a factor in the
production of catarrh. My proposition is simply this: That the
localization of catarrhal processes in the retro-na^al space or
the geographical limits of the disease have little to do with the
presence of dust in the atmosphere. While it is true that dust
accidentally lodged in the naso-pharynx may give rise to inflam-
mation, I believe that few cases originate in this way, for reasons
which I have explained in my paper.
ON THE PROLONGATION
OF THE
ANESTHETIC EFFECTS
OF THE HYDKOCHLOEATE OF COCAINE
WHEN SUBCUTANEOUSLY INJECTED.
AN EXPERIMENTAL STUDY.
By J. LEONARD CORNING, M. D.
The uses to which the various preparations of cocaine
have been put since Roller first discovered the local anaes-
thetic properties of the alkaloid are legion. To recapitulate
these manifold applications of the drug would be manifestly
a work of supererogation. Enough that they are such as
would naturally suggest themselves to an imagination of
318
CORNING: EXPERIMENTS WITH COCAINE.
[N. Y. Med. Jouk.,
average capacity familiar with the fundamental experiment
of the talented young physician of Vienna. So far as I am
aware, there has been no departure in principle involved in
the various uses to which this truly remarkable substance
has been put. And yet I believe that improvements in this
direction are not only desirable, but readily attainable. For
instance, it would be a matter of practical moment if, by
some device, we could prolong the local anaesthetic effects
of the alkaloid when used hypodermically for surgical and
other purposes. How can this object be attained ? To an-
swer this question we must for a moment consider the man-
ner in which cocaine, when subcutaneously injected, is
capable of acting upon the filaments of the sensory nerves.
In the first place, it is reasonable to infer that, after the
introduction of cocaine beneath the skin, a certain period
of time elapses during which the anaesthetic agent is dif-
fused throughout the surrounding tissue. That the blood-
stream in the capillaries renders efficient service in this pro-
cess of distribution may be accepted as proved, since, when
' the amount of cocaine injected is considerable, characteristic
constitutional symptoms are developed.
Secondly, when the terminal filaments of the sensory
nerves which ramify in the saturated tissue are exposed for
a sufficient length of time to the influence of the cocaine,
changes are set up in the nerve-substance of sufficient mag-
nitude to cause interference with conduction, and we have
all the symptoms of local anaesthesia. The more extended
and important the nerve-stems affected, the wider will be,
of necessity, the expanse of the anaesthetic zone.
But, if this is the true logic of local anaesthesia, if we
are to look upon the capillary blood-stream as the means by
which the anaesthetic substance is distributed, how does it
happen that the effects of cocaine, when subcutaneously in-
jected, are evanescent, except where large doses, frequently
repeated, are employed ? To this question I would reply
that we are to look upon the capillary circulation in a two-
fold manner : first as a distributor, it is true, but afterward
as a diluter and remover of the anaesthetic substance. The
rapid decline in the local anaesthetic effects of the hydro-
chlorate of cocaine, then, is, according to this theory, owing
to the subsequent diluting or removing attributes of the
blood-stream. The constitutional symptoms developed when
cocaine has been extensively injected for local anaesthetic
purposes constitute evidence in favor of this view.
Is it possible to adduce inductive evidence in favor of
this a priori reasoning? I believe so; but not only do I
believe that such evidence may be had for the seeking, but
I feel assured that the data thus gained may be turned to
practical account in the exigencies arising in practice.
Guided by a train of reflections in keeping with those
-detailed above, I have had recourse to a series of experi-
ments which I will first summarize as briefly as possible,
and then offer a word or two of comment, trusting that by
so doing I may not incur the criticism of being too prolix.
Experiment I. — This and the following were performed
upon Mr. A. M. Guerin, who kindly placed himself at my
disposal.
I injected five minims of a four-per-cent. solution of the
hydrochlorate of cocaine in the neighborhood of the exter-
nal cutaneous nerve of the forearm, a short distance below
and to the right of the biceps tendon. In a short time the
effects of the agent became apparent. The skin for some
distance around, and particularly below the puncture, was
anaesthetic"; After the lapse of a few minutes, judging that
the ana'sthesia had readied its maximum extent and inten-
sity, I applied an Esmarch's tourniquet around the arm a
short distance above the elbow. On examining the radial
artery, I found that the pulse was entirely obliterated.
From time to time I examined the condition of sensi-
bility in the forearm, and particularly about the region of
the puncture. After the lapse of fifteen minutes the anaes-
thesia had extended, contrary to my expectations, down the
right anterior aspect of the forearm several inches, and was
of sufficient intensity to admit of pinching and pricking ad
libitum. One of the amusements of the gentleman experi-
mented upon, at this and subsequent stages of the investi-
gation, was to thrust needles into the anaesthetic portions
of the skin, which was all the more remarkable in him in-
asmuch as he is a person of rather susceptible and nervous
temperament. When I attempted to do the like on other
portions of the integument, energetic reflex contractions
were evoked, and lively sensations of pain. After the tour-
niquet had remained in place for over half an hour the
ana'sthesia was decidedly more profound than during the
first twelve or fifteen minutes of the experiment, this pro-
fundity of insensibility being without doubt attributable to
the long saturation of the nervous filaments in the anaes-
thetic. Such saturation was evidently only rendered possi-
ble by the use of the tourniquet, which, arresting the cir-
culation, prevented the elimination and dissipation of the
anaesthetic by the blood. After the lapse of nearly forty
minutes I removed the tourniquet, not, however, because
the anaesthesia showed the slightest diminution, for the
latter, on investigation, proved to be as profound as ever,
but on account of the unnecessary tightness of the tourni-
quet, which caused the gentleman experimented upon con-
siderable inconvenience. In a few minutes after the access
of the blood to the forearm the anaesthesia began to de-
cline, and was soon entirely lost.
Experiment II. — I exsanguinated the left forearm by
means of the elastic bandage of Esmarch. I then applied the
tourniquet above the condyles as before. Ten minims of a
four-per-cent. solution of cocaine were then injected at
short intervals, the injections forming a line which extended
from the radial to the ulnar side of the upper portion of
the arm. After the lapse of ten minutes I noticed that
the inflated, blister-like elevations which marked the points
of injection were quite prominent, and showed no ten-
dency to diminish. I also ascertained, by examinations
with a needle from time to time, that the zone of anaesthe-
sia was exceedingly circumscribed, being mostly restricted
to the immediate neighborhood of the elevations at the
points of injection. Five minutes later, as there was no
appreciable diminution in the size of the elevations, and as i
there was no sigu pointing to the slightest diffusion of the
anaesthetic, I massaged the parts immediately above the
line of injections, and, having thus succeeded in causing
some diffusion of the cocaine, I was not surprised to find
Sept. 19, 1885.]
CURTIS: RADIO-ULNAR ANKYLOSIS.
319
that shortly afterward the zone of anaesthesia had increased
in ^vidth and extended in a band about an inch and a half
broad across the entire breadth of the forearm. Into this
region needles could be thrust without causing the slightest
pain or reflex action of any kind. The extension of the
anaesthesia along the districts supplied by the cutaneous
nerves of the forearm was, however, not sufficiently pro-
nounced to merit notice. This was perhaps owing to the
extremely superficial nature of the injections.
The tourniquet remained in place for over forty min-
utes, during which time the zone above described was quite
insensible to the prick of a sharp needle.
Experiment III. — I first injected five minims in the
neighborhood of the external cutaneous nerve of the fore-
arm, as in the first experiment. Five or six minutes after-
ward, however, instead of applying the tourniquet immedi-
ately, as in the first experiment, I first exsanguinated the
forearm by means of Esmarch's bandage, taking care not to
compress the tissue immediately above the point of injection.
I then applied the tourniquet. The anaesthetic zone in this
case was proportionately much larger than in the previous
experiment, following the general direction of the external
cutaneous nerve, so far as I was able to judge, in a down-
ward direction, for some three inches or more. The maxi-
mum breadth of the anaesthetic zone was perhaps a little
less than an inch.
The tourniquet was allowed to remain in place for about
an hour, during which time I was unable to note the slight-
est diminution in the anaesthesia.
Summary. — Experiment I goes to show that simple
arrest of the circulation in the part, shortly after injection
of the anaesthetic, is sufficient to prolong and intensify the
anaesthesia.
Experiment II shows that, if the injection is made after
exsanguination and compression, there is little diffusion of
the anaesthetic, and, consequently, a commensurate diminu-
tion in the number of nerve-filaments exposed to the influ-
ence of the solution. It is true, however, as we have seen,
that by the aid of massage some purely mechanical diffusion
may be produced.
Experiment III seems to prove that, if the injection is
-made a few moments before exsanguination and the appli-
cation of the tourniquet, a sufficient amount of saturation
of the tissue is obtained to expose a large number of nerve-
filaments to the influence of the anaesthetic ; and yet, unless
we wait too long, there is no danger of diluting or dissipat-
ing the solution (by the access of too much blood) to such
a degree as to weaken or nullify the anaesthetic influence.
The essential advantages of this method of local anaes-
thetization consist in our ability to expose the nerve-fila-
ments for any length of time to the influence of the anaes-
thetic. We are thus practically able to prolong the anaesthe-
sia to an indefinite degree. We are furthermore enabled to
do this by the use of comparatively small quantities of co-
caine, repeated injections being unnecessary to prolong the
anaesthesia, as is necessary when the circulation is not ar-
rested. There is, consequently, no danger of constitutional
disturbances from overdosing.
It is clear that this method may be applied in the sur-
geiy of all the extremities; and in the treatment of neural-
gias and other disorders of the peripheral nervous system it
is, I believe, destined to render good service.
26 West Fokty-seventh Street, September 14, 1885.
CONGENITAL ANKYLOSIS OF THE
RADIO-ULNAE ARTICULATIONS.
By B. FARQUIIAR CURTIS, M. D.
Omitting the cases of congenital dislocation of the
radius and those of entire or partial absence of the bones
of the forearm, we find congenital radio-ulnar ankylosis to
be a not very common deformity, even if we include those
cases in which there is also an ankylosis of the elbow or wrist
joint proper. For this reason I think the following case
worthy to be placed on record. For the opportunity to re-
port it I am indebted to Dr. William T. Bull, of this city.
Alexander McG., three years old, is the fourth child of
healthy parents. The other children are all well formed and
healthy, and so is this boy with the exception of a malformation
of the forearms. He has had one severe accident, causing the
fracture of his right clavicle, six months ago, but the recovery
has been perfect. Several months ago his parents noticed for
the first time that he did not have the full use of his arms.
Examination. — The arms, forearms, and hands of both sides
are of normal strength and of normal outward appearance, the
forearms being in a position of semi-pronation. The hands and
wrists are normal in form and motion. In both elbow-joints
flexion and extension are complete, and the bony points are in
their normal relations. But both forearms are firmly fixed in a
position midway between pronation and supination. Examina-
tion under ether gave in addition only the negative information
that the ankylosis remained as complete as before, and that no
malformation could be detected in the shape of the bones. It
was impossible to discover any abnormal deposit of bone in the
interosseous ligament or elsewhere, nor could it be decided
whether the obstruction to motion was in the superior or in
the inferior articulation, or in both.
The bilateral occurrence of the deformity, and the ab-
sence of a history and of any marks of injury or of disease,
point to a congenital malformation. The rigidity of the
ankylosis indicates a synostosis of the radius and ulna, and,
although it is impossible to say at what point this synosto-
sis has taken place, cases already on record make it probable
that it is situated at the superior end of the bones.
As to treatment, it does not seem wise to attempt any.
The forearms are ankylosed in the most favorable position,
so that the only object of treatment would be to gain the
rotary motion of the forearm. Eobert* maintains that in
cases of congenital synostosis the muscles which produce the
motions rendered impossible by that synostosis are unde-
veloped, and consequently an operation is never justifiable ;
but dissections in- such cases have indicated that the fail-
ure of development in the muscles is not always so com-
plete as he appears to believe. Still, it is very doubtful
whether any improvement could be made or not, and at this
early age an operation would be not unlikely to cause fail-
ure of growth in the bones by interference with the
* " Des vices congdnitaux de conformation des articulations.''
These de coneouts, Paris, 1851, p. 219.
320
CURTIS: RADIO- ULNAR ANKYLOSIS.
[N. Y. Mkd. Jot J!.,
epiphyses. Probably time will develop a compensatory
action of the other joints, particularly of the shoulder, which
will make operative measures unnecessary.
A careful search through the available literature shows
such a rarity of similar cases that a short account of them
may be of interest.
A. Mitscherlich (Langenbeck's " Arch. f. klin. Chir.,"
Bd. vi, p. 218) reports the following unique case:
A poorly developed girl, six years old, of healthy family, had
been relieved of double congenital club-foot by operation. Both
elbows were found partially ankylosed, flexion of the right be-
ing possible only to 70°, and of the left to 100°. Extension was
normal. Both forearms were in almost complete supination,
only a slight degree of pronation being possible. The left elbow
was resected ; the child died of pyaemia. Anatomical examina-
tion showed that in both joints the head of the radius was fixed
in front of the external half of the coronoid process of the ulna,
where it had been felt during life a9 a protuberance in the bend
of the elbow.* The lesser sigmoid cavity of the ulna was absent.
The trochlear surface of the humerus was encroached upon by a
circular articular facet for the head of the radius. A project-
ing crest divided the two articular surfaces, and it was the con-
tact of the coronoid process of the ulna with this crest which
limited flexion of the elbow, the head of the radius not coming
against the shaft of the humerus. The head of the radius was
fixed in its abnormal position by a strong ligament, which,
arising from the external condyle of the humerus and the coro-
noid process of the ulna, surrounded the neck of the radius like
the normal annular ligament. The anterior ligament of the
elbow-joint was also attached to the head of the radius.
M. Josso (" Bull, de la soc. anat. de Nantes," 12 Nov., 1879)
reports on the deformed forearm of a dissecting-room subject
whose antecedents were unknown. The superior ends of the
radius and ulna were fused together into a single bony mass, the
remninder of the bones being in extreme pronation, so that the
posterior surface of the radius presented anteriorly. The ulno-
humeral articulation was normal, but the external condyle of
the humerus was absent, as was also the head of the radius.
On the anterior surface of the common bony mass was a protu-
berance which represented the bicipital tuberosity.
Dubois (" Bull, de la soc. anat. de Paris," 1852, xxvii, p. 67)
reports a specimen of an old (congenital ?) dislocation of the
radius and ulna, the radius being elongated superiorly and fused
with the ulna from the superior limi of the interosseous space
upward. The bones were in extreme pronation.
Dr. v. Becker (Schmidt's " Jahrb.," Bd. 179, p. 13) showed
to the Vienna section of the " Ver. der Aertzte Nied. Oest." a
boy of a family among the members of which many malforma-
tions were present. He had both upper extremities deformed,
the left forearm and elbow being absent, while on the right side
the humerus was too short, and the radius and ulna were fused
into one bone one third of the normal length.
T. Jones ("Brit. Med. Jour.," 1878, i, p. 709), in describing
a case of multiple exostoses in a boy of nine years, mentions
that the patient also had a deformity of the left forearm, the
lower part of the ulna being quite rudimentary and united to
the radius, movements of rotation being impossible, but he does
not describe the position of the forearm.
Girandean ("Bull, de la soc. anat. de Paris," 1881, lvi, p. 271)
* This is the early foetal position of the head of the radius, from
which it passes outward aud backward with the growth of the parts to
the position in the fully developed joint. See Henke and Reyher,
" Ueber die Entwiekelung der Extremitiiten des Menschen," review in
Schmidt's "Jahrb.," 1875, Bd. 165, p. 225.
reports a malformation of the left forearm in a woman twenty-
six years old, the arm being small, the elbow ankylosed, the
forearm in extreme pronation, the hand deformed, the carpal
bones fused together and to the radius and ulna, and the meta-
carpal and phalangeal bones absent.
Pye-Smith (" Med. Press and Circ," Lond., 1883, Dec, p.
504) describes a family having various deformities. Among
others, we find that in the father the right hand can not be
fully supinated ; one son has the same defect in both forearms;
in a daughter neither elbow can be fully extended ; and in two
other children there exists a congenital dislocation of the radius
in one elbow.
J. II. Pooley ("Illustr. Med. and Surg.," July, 1883, p. 163)
describes a girl, ten years old, with absence of the left radius,
who had on the right side a very short curved (concave radi-
ally) forearm in which all the motions are "circumscribed and
imperfect, from what cause, however, does not clearly appear."
The right thumb was also absent.
Lenoir presented to the Soc. anat. de Paris ("Bull.," 1827,
ii, p. 95) the left forearm of a young girl who had suffered from
rhachitis, in which the bones were crossed as in pronation and
fused together for a considerable space at their upper extremi-
ties.
Congenital ankylosis of any joint, excepting those de-
formities which occur with club-foot and club-hand and in
monstrous foetuses, is so rare a condition that a few more
references will exhaust the list of recorded cases which I
have been able to find.
In the foetus at full term ankylosis has been observed
by Busch (all the joints in one case,* those of the lower
extremities in another f), Janecke (one case, J both elbows
and right shoulder), Hold (several cases *), and Becourt (one
case, || one knee) A.
In the adult and child we find only the following addi-
tional cases :
Gurlt gives a case of congenital synostosis of the second and
third cervical vertebrae, and several cases of synostosis of the
pelvic bones in deformed pelves.
Bordet (" Bull, de la soc. anat. de Paris," 1836, xi, p. 82)
reports a case of fusion of the radius and humerus, with partial
absence of the ulna, in a man of twenty-seven years.
In the same society's records ("Bull.," 1854, xxix, p. 72) is
described a specimen of bones showing fusion of the humerus
and ulna, the radius preserving "free movement"; the history
of the subject from whom it was taken is unknown.
Finally, Velpeau saw a case J in which the medullary struc-
ture of the humerus was continuous with that of the radius and
ulna, with no trace of a joint.
Volkmann| teaches that, while congenital synostosis of
the bones of the hand and foot may occur in well-developed
* "Neue Zeitschr. f. Geburtskunde," v, p. 190.-
f Ibid., xxviii, p. 233.
\ See Joulin, "Des cas de dystoeie appartenant au foetus," Paris,
1863, pp. 107 seqq.
* "Die Geburten," etc., pp. 1-230. Halle, 1850. Quoted bv Jou-
lin.
|| "Gaz. med. de Strasbourg," 1846, p. 25. Quoted by Joulin.
A Joulin refers also to Braun (" Neue Zeitschr. f. Geburtsk.," xviii^
p. 302) aud Bird ("Boston Journal," xi, No. 16), but there was no an-
kylosis in their cases.
Q " Beitrage zur vergleich. path. Anat. der Gelenkkrankh.," Berlin,
1853, pp. 159, 214.
J V. Pitha and Billroth, " Handb. der Chirurgie," Bd. II, ii, 1, p. 586.
X Ibid., p. 592.
Sept. 19, 1885.]
MOORE: ADDISON'S DISEASE.
321
subjects, when it is in the larger joints the whole extremity
is rudimentary. The truth of this statement is shown by
the fact that I have been able to find only the few excep-
tions mentioned above. I would also draw attention to the
fact that the great majority of these cases concern the upper
extremity, and to the frequency of pronation of the fore-
arm in them.
A CASE OF
DISEASE OF THE SUPRA-RENAL CAP-
SULES*
By EDWIN W. MOORE, M. D.,
FRANKLIN, PA.
Dr. Thomas Addison in 1855, by autopsical and gen-
eral evidences and by crucial analysis, associated a geometri-
cally increasing anaemia, with or without pigmentary de-
posit, with a diseased condition of the supra-renal capsules.
He furnished the profession with the pathological condi-
tions which lead up to and make the pernicious anaemia a
possibility ; he also associated the general history that this
condition is found in subjects beyond the middle period of
life and with a predisposition to the deposit of fat. As far
as my reading goes, there is but one exceptional authority: —
vide article by Samuel Wilkes, page 562, Reynolds's " Sys-
tem of Medicine," published in 1880. This gentleman takes
the position that the disease is of more frequent occurrence
before the middle period of life.
My case falls under this exceptional authority, for the
subject was of slender build, twenty-two years of age, six
feet high, and weighed about one hundred and forty-five
pounds. He was of good family history, free from in-
herited disease, and of good habits of life.
For a period of two years, and possibly more, he suf-
fered a physical depression unaccountable to himself, his
family, or his physician ; but the inroads were gradual, and
sapped his energy until he was compelled to take his bed.
My attention was first called to C. G. C. in October, 1884.
At this time I found my patient yellow, with a disposition to
bronzing, with a pearly sclerotic, with a weak, compressible
pulse, with nausea and vomiting, with furred tongue and red
margins, with pain referable to the stomach, with a history of
constipation, and, after a meal of indigestible matter, with a de-
gree of depression incompatible with general evidences. At
this time I ordered castor-oil and turpentine to unload the
primae vise, gave a hypodermic injection of morphine and
atropine to control the inordinate nervousness, and suggested
hot fomentations, sinapisms, etc.
This appeared sufficient, and with a tonic regimen he rallied,
got up, and went to his usual work. I suggested a further
general treatment, but it was not followed out.
My attention was again called to him May 1, 1885. At this
time the general evidences were increased pigmentary deposit ;
skin of face and hands as dark as any mulatto; nausea; vomit-
ing; furred tongue; constipation; pearly white sclerotic; great
feebleness and loss of vitality ; restlessness ; weak and easily
compressible pulse, rate 85 ; pain over region of capsules ; no
chill ; no fever. I directed small doses of mild chloride of mer-
* Read before the Venango County, Pa., Medical Society, July 21,
1885.
cury, guarded by morphine, to be followed by a saline ; adju-
vants, foot-bath, sinapisms, perfect rest, and artificial heat to
extremities.
May 2d. — Bowels and kidneys acted, but did not see excreta,
because patient went to bath-room ; pulse 86, temperature 97° ;
vomiting less, and yet persistent nausea ; restlessness decreased.
Directed quinine, bismuth, and morphine.
3d. — Quite comfortable ; less nausea ; tongue furred in cen-
ter and red at margins; pulse 90, feeble. Directed small doses
of calomel, pepsin, and morphine. Have directed foods and al-
coholic stimulants from the beginning, but have found a perfect
abhorrence for anything of the kind.
4th. — Tongue cleaner, moist ; pulse feeble, better sustained,
rate 90. Treatment continued.
5th. — Tongue fairly clean, moist ; pulse feeble, rate 84 ; bowel
action nil; nausea less; urine fair in quantity and quality.
Directed carbonate of ammonium and quinine, with continued
frictions, baths, etc.
6th. — Pulse better sustained, rate 86; retains nourishment
fairly well; urinary excretion one pint and a half in the past
twenty-four hours; specific gravity 1-022, acid in reaction,
dark red in color; no sediment. Continued treatment with
addition of Apollinaris water.
7th. — Pulse more feeble, rate 84; very sick at stomach dur-
ing night; vomited largely; excreta green, flaky, with mucus.
Directed rectal injection to unload lower bowel ; unsatisfac-
tory ; little faacal discharge. Added tincture of iron to treat-
ment. Mis grand-uncle, Dr. Byles, in consultation at 4 p. m.
Result, gave saline cathartic. At 9 p.m. had a thorough dejec-
tion ; discharge dark brown, with some scybala.
8th. — Pulse 86, feeble; skin moist; kidneys acted freely;
no bowel action; tongue moist and clean; nauseated dur-
ing the night, and very restless. Dr. Byles, who was in the
house, gave Dover's power to allay the restlessness and with a
hope that the ipecac might allay the nausea. Passed a very
restless night.
9th. — More comfortable than in past twenty-four hours;
bowels moved three times; stools bilious; rest fairly quiet.
Treatment continued.
10th. — Pulse more feeble, rate 96. Directed morphine.
11th. — Condition unchanged.
12th. — Resting fairly ; thinks he has had a good day. Treat-
ment continued.
13th. — Quiet; slept peacefully six hours; less nausea; urine
normal ; pulse 86, temperature 98°.
14th. — Nauseated all day ; pulse feeble, rate 90 ; urine nor-
mal in quantity, amber in color ; singultus. Added asafoetida
to treatment.
15th. — Comfortable ; facies indicates extreme exhaustion ;
circulation very feeble, rate 90; bowels moved three times;
excreta green, flakish, offensive; urine normal; tongue moist.
Directed quinine, iron, and nux vomica, with friction, and
sponging with whisky, etc.
16th. — Passed restless night ; less nausea; skin dry; kidney
action fair ; urine amber ; pulse feeble, rate 90, difficult to get
at the wrist; temperature normal; foods and stimulants ab-
horred. Dr. Byles in consultation. On account of extreme
restlessness, gave hydrate of chloral.
17th. — Pulse very feeble, and at times imperceptible ; tongue
furred in body and red at margin ; no bowel action ; skin dry
and harsh ; urine abundant ; fed by force. Directed digitalis and
arsenic, and suggested rectal injections of brandy, milk, and
beef-tea, but the patient took the same by mouth in preference.
Were retained.
18th.— No bowel action; pulse 90, with better force but
easily compressible; very restless. Mother gave hydrate of
322
LI ELL: A CASE OF CAFFEINE POISONING ; RECOVERY. [N. Y. Mbd. Job*,
chloral to allay restlessness. Patient pleasantly affected, but,
when asleep, the eyes were turned up, the lower jaw dropped;
is nervous and jerking ; haggard. Takes food and stimulants by
mouth, but with great reluctance.
19th. — Stupid ; when aroused, rational ; urine scanty ; no
bowel action; yawning, sighing, singultus; pulse feeble; nausea;
restless. Directed carbonate of ammonium, niter, and carbolic
acid to allay nausea.
20th. — 8.30 a.m. — Passed restless night ; pulse rate 90; res-
pirations hurried, lips red as usual, extremities colder, skin dry
and harsh ; vomited largely ; excreta bilious in character.
8 p. m. — Called hurriedly ; found patient pulseless, haggard,
restless, etc. Gave carbonate of ammonium, brandy, and beef-
tea per rectum. Continued to sink ; heart failure great; anx-
iety and restlessness indescribable ; remained conscious until
12.30 a. m.
21st. — Gradually became quiet, comatose, and died at 1.20,
May 21, 1885.
A resume of this history is epitomized thus : Dis-
coloration, exhaustion, pain referable to the capsular region,
pearly sclerotic, nausea and vomiting, restlessness and anx-
iety.
The discoloration through its gradations was sallow,
bronzed, smoky black, the last being the tint when last
under observation. The discoloration was general,. but was
most marked on the parts exposed to the air. The exhaus-
tion was very great, the nausea and vomiting were persist-
ent, and the restlessness and anxiety in harmony with the
heart failure.
The important feature which attracts attention is the
progressive anaemia. And it may be said that this is
largely unaccounted for.
The conditions from which it must be differentiated
are pityriasis nigra, silver poisoning, Bright's disease, sep-
tic poisons in general, and icterus.
The diagnostic points of the four first are known and
readily ascertained, but from icterus there is more difficulty
to disassociate. I will tabulate the stronger evidences :
Icteeus. Addison's Disease.
1. Slow pulse. 1. Normal to excited pulse.
2. Color sallow. 2. Color anaemic primarily,
secondarily sallow, bronzed,
smoky black.
3. Sclerotic pearly.
4. Persistent nausea and
vomiting.
5. Urine normal.
6. Bowel action torpid to
natural.
7. Appetite seriously im-
paired.
8. Debility commensurate 8. Debility greater than evi-
with poisoning. dences would indicate.
9. Nervous depression ap- 9. Depression progressive,
proaching hypochondria. with a clear mind.
In the general management of my case I found a perfect
abhorrence for alcoholic stimulants, for all stimulants, for
all foods save such as fountain water and ices.
I made no autopsy, therefore I can not describe the
supra-renal capsules, can not add anything to the sum of
pathological investigations.
3. Sclerotic yellow.
4. Nausea and vomiting.
5. Urine impregnated.
6. Bowel action torpid.
7. Appetite fair to good.
ON A RARE CASE OF
CAFFEINE POISONING; EECOVERY.
By EDWARD N. LIELL, M. D.
Cases of poisoning by caffeine are of such rare occur-
rence that a record of the following case, which came under
my observation but a short time ago, I deem may be of in-
terest :
On the morning of July 16th I was hastily summoned to see
Miss W., thirty years of age. Found her greatly prostrated and
completely exhausted, and in a state of semi-unconsciousness,
with cold extremities, clammy perspiration, and anajsthesia and
slight paresis of the muscles of the hands and feet. Temperature
normal; pulse 55, and somewhat irregular ; respirations dimin-
ished in number to 16 a minute, slightly irregular. Pupils but
slightly contracted, responding readily to light. One thing re-
markable was a persistent contraction of the flexor muscles of
the fingers and toes, with paresis of the extensors, especially of
thumbs and great toes. There was a certain spasmodic action
of the muscles of the calves of both legs, whicli, when conscious,
she termed cramp-like pains. She vomited occasionally.
I immediately applied warmth, with revulsive measures to
the extremities, and gave atropin. sulph., gr. (tablet tritu-
rates), hypodermically ; also whisky, 3j every five minutes, ad-
ministered cautiously in order to avoid exciting the vomiting.
These measures of treatment were continued, repeating the
atropin. sulph., ^ gr., bypodermically, as before, in twenty
minutes.
A change for the better was apparent almost immediately
after the second injection of atropine. She gradually regained
consciousness, when she informed me as to the cause of her ill-
ness, saying she had taken some eighteen grains of citrate of
caffeine inside of one hour and a half during the night. Her
mind was still somewhat confused, and she was exceedingly
restless and anxious.
She complained of severe paroxysmal pains in the abdomen,
simulating very much those of intestinal colic, also of a dimness
of vision, with a blur before the eyes. At one time, becoming
quite delirious, partly due to the pains in abdomen, she got out
of bed and endeavored to walk across the room, but, being un-
able to stand on her feet, reeled like one intoxicated, com-
plaining of a sudden vertigo with a feeling of numbness in the
soles of her feet, and would have fallen but for an attendant
close at hand. A certain tremulousuess of the fingers of both
hands, with tremors of tbe tongue, was present.
Thirst was excessive, with dryness of the mouth and tongue,
relieved by small pieces of ice. There was no headache what-
ever, except a fullness in the supra-orbital region. Speech was
somewhat indistinct, her utterance being at times thick, and
there was also some difficulty in deglutition. The heart's
action was diminisbed in rapidity, and its rhythm was irregular.
The bowels were constipated. The kidneys were excited to in-
creased action ; urination was frequent.
To relieve the intestinal pains, warm turpentine fomenta-
tions were applied over the hypogastrium, the nausea and vomit-
ing being relieved by the following : R Sodii bromid., 3 ss. ;
bismuth, subnit., gr. x ; acid, hydrocyanic, dil., gtt. j. M. This
dose was repeated in fifteen minutes.
About three quarters of an hour after my arrival she com-
plained rather suddenly of a severe cramp in the muscles of the
calves of both legs, extending upward, gradually implicating the
muscles of the abdomen, chest, and neck, when a sudden and
severe convulsive seizure followed, of a marked tetanic charac-
ter, tbe abdominal and chest muscles becoming retracted and
Sept. 19, 1885.]
BOOK NOTICES.
323
rigid ; the eyes were suffused, and the facial expression was
that of great pain, the respirations being entirely checked and
cyanosis very 'prominent, with the jaws quite rigid, and the fin-
gers firmly contracted. This was followed by a second convul-
sive seizure of the same character some three minutes later.
R Chloral, hydrat., gr. xv, potass, broraid., 3ij, was then
given at one dose, and repeated within half an hour'. This had
the effect of checking the convulsions and rendering the patient
quiet. When she recovered sufficiently to collect her thoughts
the following history was obtained:
After a somewhat immoderate use of stimulants the previous
day, and having been up the greater part of the night before she
complained of a severe headache and of being very nervous,
when a friend advised her to take a two-grain powder of
citrate of caffeine ; misunderstanding the quantity directed,
she had prepared and took a three-grain powder instead.
Not getting instant relief, she repeated the dose, and had taken
six powders (eighteen grains in all) within one hour and a half,
when she began to feel the effects of the combined doses. In
the mean time she had sent out for some quarter-grain mor-
phine pills, but had only taken one, being prevented from tak-
ing more by a high state of mental excitement. (It may be
mentioned here that, according to her statement, she had never
been subject to hysteria, but was naturally of a very nervous
and excitable temperament.)
During the night she was exceedingly restless and wakeful,
tossing about the bed one moment and the next moment walk-
ing the floor, the insomnia being persistent, which, combined
with her excited condition, bordered on delirium. Respiration
was at the time disturbed, her breathing becoming hurried and
irregular, with excited and irregular heart action. Reflex ex-
citability was quite marked for a time, when general muscular
weakness supervened. In this condition she passed the night,
conscious of what was going on and recognizing things about
her.
Toward morning the delirium gave way to a condition of
stupor or semi-unconsciousness, in which state I found her.
After the second dose of chloral and potassium bromide was
given her she fell into a quiet slumber, lasting about an hour,
when she awoke without manifesting any untoward symptoms
or signs of her late trouble, except that a certain stiffness of the
muscles, especially of the lower extremities, remained.
From this time on, with rest and quiet in bed, under the
treatment described and light stimulating diet, she improved rap-
idly, the vomiting having entirely ceased, and the ill effects of
the caffeine disappeared. The anaesthesia, with paresis of the
muscles of the hands and feet, began to gradually diminish,
disappearing entirely on the fifth day.
Sodium bromide, in thirty-grain doses every four hours, was
kept up for some two days thereafter.
In conclusion, a brief resume of the peculiar effects of
caffeine upon the system may not be amiss. They may be
divided into two stages — that of excitement or delirium, and
that of depression or stupor with unconsciousness.
During the first (stage of excitement) the heart action is
accelerated ; the pulse is increased in frequency ; the respira-
tions are more or less rapid and irregular ; there arc restless-
ness, persistent insomnia, with confusion of mind, and in-
creased activity of the kidneys. Delirium may or may not
be present, the person retaining full consciousness of what
is going on and recognizing everything about him. Colicky
pains with occasional vomiting are also present. Following
on this comes the second (stage of depression) : the heart
action and pulse are diminished in frequency ; the respira-
tions are below normal; the pupils are slightly contracted;
there are persistent contractions of the flexor muscles of the
fingers and toes, with anaesthesia of the same, and paresis
of the extensors; there are cramp-like pains, with weakness
and stiffness of the muscles of the calves of the legs; there
is no cephalalgia, but, later on, stupor or unconsciousness.
In this special case almost twelve hours had elapsed from
the time of her taking the powders until I was summoned.
As to the controversy in various medical works whether
true convulsions are ever produced by caffeine in human be-
ings, it is a settled fact in my mind that they do occur, as
proved in this case.
268 West Thirty-eighth Street.
cflh Notices.
BOOKS AND PAMPHLETS RECEIVED.
Index-Catalogue of the Library of the Surgeon-General's
Office, United States Army. Authors and Subjects. Vol. VI.
Heastie-Insfeldt. Washington: Government Printing-Office,
1885. Pp. 11-1051.
A Treatise on Nervous Diseases ; their Symptoms and Treat-
ment. A Text- Book for Students and Practitioners. By Sam-
uel G. Webber, M. D., Clinical Instructor in Nervous Diseases,
Harvard Medical School, etc. New York : D. Appleton & Co.,
1885. Pp. ix^!15.
The Use of the Microscope in Clinical and Pathological Ex-
aminations. By Dr. Carl Friedlaender, Privat-Docent in Patho-
logical Anatomy at Berlin. Second Edition, Enlarged and Im-
proved, with a Chromo-lithograph. Translated, with the Per-
mission of the Author, by Henry C. Coe, M. D., M. R. C. S.,
L. R. C. P. (London), Pathologist to the Woman's Hospital in
the State of New York. New York : D. Appleton & Co., 1885.
Pp. x-195.
A Complete Pronouncing Medical Dictionary : embracing
the Terminology of Medicine and the Kindred Sciences, with
their Signification, Etymology, and Pronunciation. With an
Appendix, comprising an Explanation of the Latin Terms and
Phrases occurring in Medicine, Anatomy, Pharmacy, etc.; to-
gether with the Necessary Directions for Writing Latin Pre-
scriptions, etc. By Joseph Thomas, M. D., LL. D., Author of
the System of Pronunciation in Lippincott's "Pronouncing
Gazetteer of the World," etc. On the Basis of Thomas's " Com-
prehensive Pronouncing Medical Dictionary." Philadelphia:
J. B. Lippincott Company, 1886. Pp. 844.
Acne: its ^Etiology, Pathology, and Treatment. A Practi-
cal Treatise based on the Study of One Thousand Five Hundred
Cases of Sebaceous Disease. By L. Duncan Bulkley, A. M.,
M. D., Physician to the New York Skin and Cancer Hospital,
etc. New York and London : G. P. Putnam's Sons, 1885. Pp.
x-280. [Price, $2.]
Moisture and Dryness; or the Analysis of Atmospheric Hu-
midities in the United States, etc. By Charles Denison, A. M.,
M. D., Professor of Diseases of the Chest and of Climatology,
University of Denver, etc. Chicago : Rand, McNally & Co.,
1885. Pp. 30 and charts. [Price, $1.]
Health Statistics of Women College Graduates. Report of
a Special Committee of the Association of Collegiate Alumna?,
Annie G. Howes, Chairman, etc. Boston : Wright & Potter,
State Printers, 1885. Pp. 78.
First Annual Report of the New York Cancer Hospital.
324
CORRESPONDENCE.— L EA MS 0 AR TICLES.
[N. Y. Med. Joou.,
Oleate of Manganese. By Franklin EL Martin, M. D. Read
before the Chicago Medical Society, Augii8t 3, 1885.
A New Bandage for Fixation of the Humerus and Shoulder-
Girdle. By Charles W. Dulles, M. I)., etc. [Reprinted from
the "Medical News."]
Complete Laceration of the Perinaeum, etc. By A. B. Cook,
A. M., M. I)., etc., Louisville. [Reprinted from "Gaillard's
Medical Journal."]
Corrtsponbintc.
LETTER FROM BOSTON.
The Boston Water - Supply.
Boston, September 1£, 1885.
In my last letter I gave a general outline of the way in which
our water-supply is contaminated. I will now go more into
detail as to one source. One of the acts of the recently dis-
placed Water Board, and one upon which they prided them-
selves, was the purification of the various water-basin«, but
especially that known as " Ashland, No. 4." This is situated in
the town bearing its name, and is on a tributary of the Sudbury
River known as Cold Spring Brook. This basin is the largest,
of the Sudbury system. It covers an area of 270 acres, and,
when full, will hold 1,100,000,000 gallons of water. It runs
through a deep, narrow valley, with high hills rising abruptly
on either side. It arises from various springs. The valley con-
sists largely of bogs, and the black mud is very deep in places,
with a hard, clean, sandy bottom beneath it, from which hun-
dreds of springs bubble up. During the construction of the
basin work was going on in making new parks in Boston, and,
as the loam was needed, it was removed and taken to the city.
But, as the excavation progressed, it was found that deep pock-
ets of muck or peat existed, extending in some cases over acres
and to the depth of seven or eight feet. Beneath them there
was a layer of hard, green sand, which was perfectly pure.
With the experience of Farm Pond (where the same state of
things existed) still fresh in the minds of the people, one would
think that the Water Board would have acted in accordance,
but, instead of the muck and decaying vegetable matter being
hauled out, the surface was simply skimmed, and a thin layer
of gravel put over it.
The estimated expense of the work at this basin is a little
short of $1,000,000, and yet, after this outlay, the water, which
comes from the springs pure and sparkling, is so contaminated
that it is not fit for use, and, in order that the money already
spent may not be lost, this whole area will have to be dredged
till the hard subsoil is reached, after which we may expect the
water from the springs to reach us in something like purity.
The brook that connects Basin No. 2 with No. 4 not only has
it3 water defiled by the same kind of decomposing material, but
also receives the drainage from the houses on its course. This
brook also will have to be thoroughly dredged, and the out-
houses and other sources of contamination removed, other out-
lets being provided for the sewage.
Many of our people do not believe that the condition of
things is so bad as it is reported, saying that they have no
trouble in their houses. If such people will inspect their water-
tanks they will soon be convinced. In many instances that I
know of, two or three inches of muck and detritus have been
found on making such an examination. In places where water
is drawn from the street-main direct, without the intervention
of a tank, and the water is allowed to settle, the presence of
foreign matter is easily detected.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D Appleton & Co. Frank P. Poster, M. D.
NEW YORK, SATURDAY, SEPTEMBER 19, 1885.
THE SURGEON-GENERALSHIP OF THE MARINE-HOSPITAL
SERVICE.
In far greater measure than commonly falls to the lot of
public officials, even medical officers, has Surgeon - General
Hamilton had to contend with envy, hatred, and malice, and
all uncharitableness. Thus far he has manfully and success-
fully striven against these malign influences, while he has not
deviated from the decorousness and fairness that should always
characterize officers of the Government. At the same time, by
his careful, prompt, and unostentatious use of the Congressional
epidemic fund, he has shown the utter groundlessness of what-
ever genuine distrust may at one time have been felt of the
committal of such grave and comprehensive responsibilities to a
single individual. Add to this the efficient and satisfactory
conduct of the Marine-Hospital Service that has marked his
incumbency of the chief office of that bureau, and we certainly
have the picture of a faithful performance of duties that entitles
him to the highest consideration.
And yet there are rumors — but too well founded, we fear —
of serious and determined efforts to displace him. There is no
pretense, as we understand matters, that any fault is found
either with his capabilities or with his official acts, except, in-
deed, in so far as they may have been distasteful to some soi-
dimnt sanitarian; but the honors and the emoluments of his
position are coveted as the means of paying off a debt of grati-
tude to some one of a number of political " worker?."
If there were any serious danger of the success of these
plots against Dr. Hamilton — and we shall decline until com-
pelled to the contrary to believe that there is — the situation
would be grave enough, in these times of civil-service reform,
even supposing that his office was one that made him subject
to the vicissitudes of the spoils system as heretofore inter-
preted by politicians. But the post of surgeon-general of the
Marine- Hospital Service is one to which Dr. Hamilton rose in
quite the same way as a surgeon-general of the army usually
arrives at his position, in accordance with considerations partly
of seniority and partly of the good of the service. Such ap-
pointments are commonly made in complete disregard of par-
tisan motives, and the tenure of office is regarded as secure, in
the absence of special cause. Even the machine politicians
pass the office over as beyond their grasp.
It is said that a high official of the Government is one of
those who have set their covetous eyes on the surgeon-general-
ship of the Marine-Hospital Service. If this is true, it is re-
assuring to observe that he is not the only one, for non-inter-
ference may prove to have its firmest ground in the antago-
nisms of rival schemers. Fortunately, however, it is not in
Sept. 19, 1885.]
MINOR PARAGRAPHS.
325-
this reflection alone that Dr. Hamilton's undisturbed possession
of the office he has adorned finds its chief guarantee; if all
indications are to be interpreted in accordance with their plain
drift, neither the President nor the Secretary of the Treasury
is the sort of man to remove the present surgeon-general with
no other motive than to make way for some aspirant whose
pretensions may be urged on personal or partisan grounds.
SMALL-POX.
The country has been measurably free from small-pox for a
considerable period. Limited outbreaks have occurred here
and there at various times, but there have been none of suf-
ficient magnitude to arrest public attention. In particular, the
metropolis, where epidemics might naturally be expected to take
their start, has, thanks to the vigilance and energy of the boards
of health of New York and Brooklyn, been exceptionally free
from the disease for a long term of years. Even in the "pan-
demic" of 1871 to 1873, when Boston, Philadelphia, and Chica-
go suffered severely, New York was but lightly attacked ; and
since that time it has been quite the exception for small-pox to
figure in our reports of infectious diseases. All this should not
lull us into a false feeling of security, however. Thus far — and
it is well on toward cold weather — we have escaped the cholera,
of which the community has stood somewhat in dread, but for
several weeks past there have been warnings which we can not
afford to disregard of one of those epidemic waves that have
always marked the history of small-pox.
During the greater part of the summer the disease has been
rife in Montreal, a city which is in close communication with
the United States, and which seems to constitute, so to speak,
an ever-active nursery of the infection, in consequence, it ap-
pears, of the peculiar obstinacy displayed by a large proportion
of its population in opposing vaccination. For a number of
weeks, too, it has not been an uncommon occurrence for vic-
tims of the disease to effect a lodgment in New York from im-
migrant ships, especially those coming from Germany. A no-
table instance of this sort came to light week before last, when
a lad was found in a house in Pitt Street who is said to have
arrived recently by a German steamship, and to have had small-
pox for a week before the nature of his illness was made known.
Ordinarily such an event would have little significance, even
although, as in this instance, the sufferer was lodged under the
same roof that covered a daily assemblage of school-children.
Taken, however, in connection with the undiminished and ap-
parently increasing prevalence of variola in Montreal, and its
isolated outbreaks in various localities in our own country — at
Fall River, for example — it can scarcely be viewed with the
equanimity that might otherwise be felt.
Not the least significant of the circumstances that should
put us on our guard is the fact that the occurrences alluded to
have taken place in summer. It is usually in cold weather by
preference that small-pox proves epidemic, but it may not be
amiss to recall that the great epidemic of the last decade, which
swept the greater part of our country, made its first decided
outbreak in Lowell, Massachusetts, during the summer. It
would perhaps be going too far to argue from that that an epi-
demic arising in summer was particularly likely to prove unusu-
ally destructive, but it is difficult to avoid the thought.
It is with no desire to play the alarmist that we have thrown
out these suggestions, but simply to put our readers on their
guard. In the case of small-pox, however, there need be less
hesitation in sounding the alarm than with regard to most other
pestilential diseases, for popular anxiety may readily be ex-
changed for security ; prevention is within every man's reach.
MINOR PARAGRAPHS.
NEWSPAPER NOTORIETY.
We quite agree with our correspondent who signs himselt
"Practitioner." On several occasions we have expressed our-
selves in regard to the rage for newspaper notoriety which
seems to have blinded some of our brethren to the decency and
modesty of a trujy scientific life. If we have restricted our re-
marks to those outcroppings of this spirit which have appeared
in New York, it is because we have preferred to try to set
things right at home before criticising our colleagues elsewhere,
and by no means because we have been willing to confess that
the offenses referred to have been in any way peculiar to our
immediate neighborhood. The metropolis, as being presumably
the most advanced in civilization of all places on the continent,
should certainly be freest from the foibles of a callow commu-
nity. If our own sense of propriety did not urge this upon us,
we should at least be spurred on to it by the comments which
reach us from other parts of the country, and our excellent
contemporary the " Medical News," of Philadelphia, has lately
made pointed and most amply justified allusion to the breach of
taste in question. Moreover, New York is in a certain sense
on trial before the country ; it is here that the formal restric-
tions of the code of ethics have in a measure been cast off, and
that very fact makes it all the more incumbent on us to show
that there are other incentives to a decorous course of life.
Our readers will have no difficulty in imagining what the occur-
rences are to which our correspondent alludes, and we will
therefore only add an expression of the hope that no more spe-
cific reference to them may be necessary to recall our erring
brethren to a proper sense of what is due their own dignity as
well as that of our common profession.
THE CURIOSITIES OF LOCAL ANAESTHESIA.
In this issue of the Journal we publish two communications
which set forth remarkable facts connected with the subject of
local anaesthesia. We refer to Dr. Coming's article and to Dr.
Halsted's brief letter. The explanation given by Dr. Corning of
the decided prolongation of the effects of cocaine which he has
been able to obtain by annulling the local circulation for the
time being is apparently correct and very creditable to his in-
genuity. Indeed, it is hardly fair to speak of it as an explana-
tion ; it was rather the conception which led to the experi-
ments. If further trial shows that the practice is free from
drawbacks which can not now be foreseen, an immense addi-
tion will undoubtedly be found to have been made to our re-
sources in local anesthetization.
Quite as striking and no less interesting, even if its practical
utility should prove to be more restricted, is the curious fact set
forth by Dr. Halsted, that the intra-cutaneous injection of sim-
ple water, properly managed, is capable of giving rise to a tem-
porary and circumscribed anaasthesia. In the light of these two
contributions to our knowledge, we may well indulge in the
326
MINOR PARAGRAPHS.
[N. Y. Med. Joub.,
fond anticipation that, general anesthetization, with all its at-
tendant inconveniences, may soon he found necessary only in
exceptional cases.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending September 15, 1885 :
DISEASES.
Week ending Sept. 8.
Week ending Sept. 15.
Cases.
Deaths.
Cases.
Deaths.
Typhoid fever
36
10
48
9
Scarlet fever
15
1
24
1
Cerebro-spinal meningitis ....
1
1
5
5
3
1
1
0
Diphtheria
35
15
38
18
Small-pox
2
0
2
0
The International Medical Congress.— We learn that Dr.
E. B. Maury, of Memphis, Tenn., declined the honor of serving
as one of the vice-presidents of the Section in Obstetrics and
Gynaecology as soon as he received the notice of his appointment.
The New York Post-Graduate Medical School and Hos-
pital.—We have received the first issue of the li Quarterly Bulle-
tin." published by the Clinical Society -connected with this in-
stitution, and we find it a very creditable production. It con-
tains a well-executed chromo-lithograph showing a syphilitic
affection of the lung. The Faculty announce the following
courses for the winter of 1885-'86 : Diseases of the eye and ear,
nineteen hours a week, and a course in the operative surgery of
the eye as frequently as classes are formed ; diseases of women,
obstetrics, and the anatomical basis of gynaecology, sixteen
hours a week ; general, minor, operative, and orthopaedic sur-
gery, nineteen hours ; diseases and the anatomy and physiology
of the nervous system, twenty-one hours ; diseases of the throat
and nose, six hours; clinical medicine and therapeutics, urinary
analysis, and work in the histological and pathological labora-
tory, twenty-one hours ; venereal diseases, ten hours; diseases
of the skin, six hours; diseases of children, twenty-seven hours.
Opportunities will be afforded the class to witness autopsies at
the Presbyterian Hospital, as well as those that occur in the
practice of the instructors in the children's department. The
laboratories will be open all day, and every possible means will
be employed to facilitate instruction. It will be seen that the
institution offers its pupils one hundred and forty-four hours
of clinical and practical instruction every week.
A Testimonial to Professor Koch.— The "Medical Times
and Gazette," of London, says: ''A testimonial has been re-
cently presented to Geh. Med.-Rath Professor Dr. Koch by the
practitioners who last winter attended his course of lectures on
cholera at the Reichsgesundheitsamt, Berlin. It consisted of an
ebony casket richly ornamented in silver, having a silver shield
in front bearing the inscription 'Dedicated to Herrn Geh. Med.-
Rath Professor Dr. Robert Koch with thankfulness by his first
pupils, Berlin, 1884-'85.' A silver plate is let into the lid, on
which, in raised work, is a bust of Dr. Koch, on a pedestal,
against which the goddess Hygeia leans holding in the one hand
the staff entwined by the serpent, the symbol of the medical art,
and in the other a laurel crown. A nude child seeks to conceal
itself amidst her flowing drapery in fear of a haggard woman at
the foot of the pedestal, who with a scythe in her hand symbol-
izes the devastating disease which Dr. Koch has chosen for the
special object of his study. On either side of the pedestal are
groups of palms. Prof. Echtermeyer is the author of the de-
sign for this relief. The casket is lined inside with dark blue
satin plush."
The University of Vienna.— The " Medical Times and Ga-
zette" learns that Prof. Fuchs, of Liege, is likely to be given
Prof. Jiiger's chair of ophthalmic surgery.
Army Intelligence.— Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from September 6 to September 12, 1885 :
MoKee, J. C, Major and Surgeon. Sick leave still further ex-
tended three months on surgeon's certificate of disability.
S. 0. 204, A. G. O., September 7, 1885.
Patzki, J. H., Captain and Assistant Surgeon. Assigned to
duty as post surgeon, Jackson Barracks, New Orleans, La.
S. O. 192, Department of the East, September 8, 1885.
Poliiemus, A. S., First Lieutenant and Assistant Surgeon.
When relieved at Fort McDermit, Nev., assigned to tempo-
rary duty at Presidio of San Francisco, Cal. S. O. 87, C.
S., Department of California.
Kendall, William P., First Lieutenant and Assistant Surgeon.
Relieved from duty at Presidio of San Francisco, Cal., and
assigned to duty as post surgeon at Fort McDermit, Nev.,
relieving Assistant Surgeon Polhemus. S. 0. 87, Depart-
ment of California, August 31, 1885.
Naval Intelligence. — Official List of Changes in the Medi-
cal Corps of the United States Navy during the weelc ending
September 5, 1885.
Stewart, Henry, Surgeon. Leave of absence extended one
year from October 15th, with permission to remain abroad.
Steele, John M., Passed Assistant Surgeon. Detached Septem-
ber 1st from Constellation, and to report for duty at Naval
Academy, Annapolis, Md.
Bright, George A., Surgeon. Detached September 1st from
Constellation, and to wait orders.
Dickson, S. H, Passed Assistant Surgeon. Ordered to Naval
Academy, Annapolis, Md., as relief of Passed Assistant Sur-
geon A. A. Austin.
Fitts, Henry B., Assistant Surgeon. Detached from Coast-
Survey steamer Gedney, and to wait orders.
Austin, A. A., Passed Assistant Surgeon. Detached from Naval
Academy, Annapolis, Md., and ordered to Coast-Survey
steamer Gedney, to relieve Assistant Surgeon H. B. Fitts.
Society Meetings for the Coming Week :
Monday, September 21st: Medico-Chirurgical Society of Ger-
man Physicians (New York) ; Hartford City, Conn., Medi-
cal Association ; Chicago Medical Society.
Tuesday, September 22d : New York Dermatological Society;
Buffalo Obstetrical Society (private) ; American Gynaeco-
logical Society (first day — Washington); Medical Society of
the County of Lewis (quarterly), N. Y.
Wednesday, September 23d : New York Pathological Society ;
American Microscopical Society of the City of New York;
Philadelphia County Medical Society (conversational); Amer-
ican Gynaecological Society (second day).
Thursday, September 24th: New York Academy of Medicine
(Section in Obstetrics and Diseases of Women and Children) ;
Harlem Medical Association of the City of New York ; New
York Orthopaedic Society; Roxbury, Mass., Society for
Medical Improvement (private) ; Pathological Society of
Philadelphia (conversational); Cumberland County, Me.,
Medical Society (Portland) ; American Gynaecological Soci-
ety (third day) ; New London County, Conn., Medical So-
ciety (extra — New London).
Friday, September 25th: Yorkville Medical Association (pri-
vate) ; New York Society of German Physicians ; New York
Clinical Society (private) ; Philadelphia Clinical Society ;
Philadelphia Laryngological Society.
Sept, 19, 1885.)
LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES.
327
fetters trj % <&Hxtox.
WATER AS A LOCAL ANAESTHETIC.
September, 16, 1885.
To the Editor of the New York Medical Journal:
Sir : My communication on the use and misuse of cocaine,
as published in the latest number of this Journal, appeared,
through an oversight of mine, minus a foot-note which, refer-
ring to the passage introduced by the word " into " (italicized,
and occurring eight lines before the last one in the printed arti-
cle), bad been appended to the original manuscript.
Apropos of cutaneous as distinguished from subcutaneous in-
jections, I would like to present now the statements which were
to have been embodied, more briefly, in the foot-note.
1. The skin can be completely anaesthetized to any extent by
cutaneous injections of water.
2. I have at times, of late, used water instead of cocaine in
minor operations requiring skin incisions.
3. The anaesthesia seldom oversteps the boundary of the
originally bloodless wheal, but does not always vanish just as
soon as hyperemia supervenes.
W. S. Halsted.
NEWSPAPER NOTORIETY.
To the Editor of the New York Medical Journal:
Sir: Will you not give expression in the Journal to the
sentiment of contempt so generally excited by the vulgar news-
paper notoriety that appears to have been sought by several
of the profession in the city during the last few months? Re-
cent items, with which you must be familiar, have been so pe-
culiarly offensive and numerous that the time for a public re-
buke appears to have come. I hope your judgment will confirm
this opinion, and that you will remind the offenders of the im-
propriety of their action, and warn them that notoriety is not
reputation, or rather that it is reputation of a kind that can
only do them harm.
If the matter concerned only the offending individuals, we
might look on in silence at their vulgar vanity and their ex-
ploitation of "wonderful cases" or fortuitous connection with
prominent personages; but, unfortunately, the profession is
held to a measure of responsibility for the acts of its members,
and upon each of us falls some portion of the contempt so freely
expressed for them.
Practitioner.
NEW YORK OBSTETRICAL SOCIETY.
Meeting of March 17, 1885.
The Vice-President, Dr. P>. McE. Emmet, in the Chair.
A Dilating Forceps.— Dr. W. T. Lose showed a forceps,
with narrow blades, which he had found very useful in several
cases for the purpose of dilating the cervix.
Dr. E. L. Partridge thought it undesirable to employ blades
which had so much spring, since there was danger of compress-
ing the child's head unduly.
Dr. Lusk explained that he only aimed at dilating the cer-
vix with this forceps, the delivery being subsequently effected
with a different one.
Pyo-salpinx. — Dr. J. B. Hunter resumed the discussion be-
gun at the preceding meeting, presenting three additional speci-
mens of pyo-salpinx. He gave the following resume of the most
important symptoms which be had noted: "In reviewing the
cases of pyo-salpinx of which I have presented specimens to
this society, and others which I have had opportunities of ob-
serving, I am inclined to think that there are certain symptoms
and physical signs by which these cases may be distinguished,
not only trom those significant of ovarian disease, but also from
other and les3 serious diseases of the tubes themselves. The
symptoms common to suppurative disease of the Fallopian tubes
I believe to be: Severe pain two or three days before menstru-
ation, located in the affected side and running down the cor-
responding limb ; constant pain during the menstrual period ;
comparative freedom from pain for a week or ten days after
its cessation ; profuse menstruation, and sometimes constant,
though slight, metrorrhagia; a discharge of pus (having fre-
quently an offensive odor) after the flow has ceased. The physical
signs are: A mass is found posterior to the uterus, often so hard
that it is mistaken for a fibroid tumor; the uterus is enlarged,
globular in shape, and generally movable. When palpated after
a period, the organ appears to be smaller than before, and the
tumor behind it feels softer. There is often so much general
tenderness around the uterus that an accurate examination is
only possible during anaesthesia. In cases of hydro-salpinx
(which it is important to differentiate from those of pyo-salpinx)
the tubes are often much larger, and are, as a rule, freely mova-
ble, not being adherent to the uterus. Another point of differ-
ence between the two is that, while there may be a considerable
amount of local pain in hydro-salpinx, there is not so much
general disturbance as in suppurative inflammation of the tubes ;
in the latter case there is a marked deterioration of the pa-
tient's health from month to month. Doran, in his recent work
on the ovaries and tubes, says: 'There can be no doubt that
some of the most intractable cases of pain in the pelvic and
iliac regions, often attributable to other causes, are really due
to disease of the tubes.' The pain due to ovarian disease un-
complicated with tubal disease is of a more intermittent char-
acter, and is generally referred not only to the affected region,
but also to the breast on the same side, and is very commonly
accompanied by nausea — a symptom which is not noticed when
the tube alone is affected.
" It is important to distinguish between catarrhal and puru-
lent affections of the tube, because the treatment is radically
different ; cases of pyo-salpinx go on rapidly from bad to worse,
and probably never recover without surgical interference, while
simple hydro-salpinx, not complicated by serious ovarian dis-
ease, is not dangerous to life, and may remain stationary for
years."
In conclusion, Dr. Hunter quoted recent statistics of Hegar's
operations, which seemed to prove that the ovaries and not the
tubes (as maintained by Tait) were actively concerned in the
function of menstruation. Out of 134 patients (from a total of
149) who recovered from the operation there was a marked
diminution of the size of the tumor, together with a cessation
of the menses in 76 cases. It was certain that the premature
menopause could not be effected by removal of the tubes
alone.
Dr. Warren asked if the speaker had not general! v noticed
a displacement of the uterus in his cases.
Dr. H unter replied that this was frequently, but not in-
variably, the case.
Dr. II. C. Coe protested against the commonly received
opinion that nearly all cases of pyo-salpinx could be traced di-
328 PROCEEDINGS
• =
rectly to gonorrhoea! infection. He thought that it was ex-
tremely difficult to trace this sequence, and was inclined to
believe that many authors had simply copied their statements
from others without taking the trouble to verify them. He had
examined specimens of pyo-salpinx removed from unmarried
females and from other patients in whose cases it was impossi-
ble to establish any previous specific affection ; moreover, tubal
disease was occasionally seen in animals, as had been shown by
Mr. Sutton in his report of autopsies made at the London
Zoological Gardens. As a rule, however, hydro-salpinx was
the condition generally found in animals.
Dr. W. G. Wylie thought that a history of previous gonor-
rhoea could be obtained in many cases, but that post-puerperal
septic endometritis was the most common cause of pyo-salpinx.
He said that he had purposely kept cases of gonorrhoea under
observation in order to see how they would terminate In two
instances undoubted peritonitis developed from a direct exten-
sion of the specific inflammation. A third cause was undoubtedly
simple catarrhal inflammation of the uterine mucous membrane.
Dr. E. Noeggerath stated that there were, in all, five va-
rieties of salpingitis, viz.: tubercular, syphilitic, actinomycotic,
gonorrhoea!, and septic. As regarded the most common cause
of salpingitis, he did not propose to discuss its gonorrhoea]
origin, because those of the profession who formerly opposed his
views most strongly had now accepted them, among others
Hegar, Martin, Haeser, and many of the most prominent Ger-
man gynaecologists. As regarded the variety to which Dr.
"Wylie had referred, and which he had designated as "septic
salpingitis," Dr. Noeggerath said that many cases of salpingitis
which followed premature delivery and were apparently of sep-
tic origin could be traced to a latent gonorrhoea, which had
been the direct cause of the abortion. He cited a case in which
a specific endometritis that had existed before pregnancy reap-
peared after delivery. He acknowledged that it was difficult
to prove the causative relation in which gonorrhoea stood to
pyo salpinx, because the former disease, as communicated by
the man, was always of a chronic nature, and therefore it was
not easy to trace its beginning; in order to establish positive
facts, a large number of observations must be made. " Sup-
pose," said he, " we admit that septic salpingitis does arise from
a purely septic endometritis ; we do not know the true nature of
the infection, because we are only just beginning to understand
what puerperal septicaemia is." In order to prove the entity
of a puerperal salpingitis, it would be necessary to trace the
•disease from the endometrium directly into the tubes ; but this
had not yet been done. A great change would be occasioned
in the current views upon salpingitis if the characteristic gono-
•coccus could be found in the morbid contents of the tubes. He
had searched for it in the fluid from dilated tubes, but hitherto
without success. He thought that, undoubtedly, other varieties
of salpingitis would be discovered, due to the presence of other
■characteristic microbes. He had examined very carefully a
drop of pus from one of Dr. Hunter's specimens, and had cul-
tivated two varieties of micrococcus found in it, both of which
resembled the gonococcus, but could not be considered as iden-
tical with that microbe. It was possible that the coccus of
gonorrhoea might change its characteristic form after entering
the tube, since it was then in a new soil and subject to new in-
fluences; but this intricate matter could not bo settled without
a large number of observations.
In reference to the matter of diagnosis, Dr. Noeggerath re-
ferred to a remark made by Dr. Wylie at the preceding meeting,
that it was not necessary to make out the actual presence of
enlarged tubes in order to justify an operation, provided the
local symptoms were sufficiently urgent.
He showed an instrument which he had found useful in cases
OF SOCIETIES. [N. Y. Mep. Jock.,
in which it was desirable to make an exact diagnosis. It con-
sisted of a double hook opening outward, one arm of which
terminated in a long extremity resembling a uterine sound.
The sound was introduced so far into the uterine cavity that
the hooks were half an inch within the cervix ; the uterus was
then pulled downward by an assistant, while the surgeon, with
one finger in the rectum and the other hand upon the abdomen,
could thoroughly explore the pelvis. The uterus could be
moved toward or away from the examining finger, and the ap-
pendages could be more perfectly examined than in any other
way. If necessary, the urethra could be gradually dilated (the
process being repeated two or three times a day for two or
three weeks) until the forefinger could be passed into the blad-
der, when the ovaries and tubes could be plainly felt. It was
sometimes very important to be able to make an exact diagnosis,
because it made a great deal of difference in the prognosis of
an operation whether the tubes were much diseased or were
unaltered themselves, but were surrounded by inflammatory
adhesions. In the former case the prognosis was good, but
where the symptoms were due to other causes than diseased
tubes or ovaries it was unfavorable. If, however, there was a
history of a subacute peritonitis which had become chronic, one
could infer, in nearly every instance, that the tubes were dis-
eased and that an operation was necessary. Disease of the
tubes was the cause, and not the result, of the perimetritis.
There were peculiar conditions in individual patients which it
was important to recognize; as an example, he cited the case
of a lady who had an attack of acute perimetritis six years ago,
and had been under treatment ever since. He examined her
six months ago by the method before described, and found both
ovaries atrophied, the tubes being only slightly enlarged, but
buried in a mass of adhesions, whereupon he refused to oper-
ate. It was in such a case as this that the instrument devised
by him had proved most useful.
Dr. Wylie had not wished to give the impression that he did
not try to make an exact diagnosis in cases of enlarged tubes ;
on the contrary, he always made a practice of keeping his pa-
tients under observation for weeks, or even months, before
operating, so that he was frequently enabled to clear up the in-
flammatory deposits sufficiently to ascertain the precise condi-
tion of the appendages. He disapproved of the practice of
pulling down the uterus for diagnostic purposes in these cases,
or even of passing a sound into the cavity, since there was great
danger of lighting up peritonitis. By anaesthetizing the patient
and passing the left forefinger into the rectum, he could ordi-
narily map out the pelvic contents and detect any enlargements
in the broad ligaments. In some instances he could not decide
whether the tumor was an enlarged ovary or a tube. (Speci-
mens were shown illustrative of this difficulty.)
Dr. Hunter agreed with Dr. Wylie in his disapproval of
forcibly depressing the uterus. To illustrate the difficulty
which was sometimes experienced in diagnosticating pyo-salpinx
he mentioned a case in which several experienced gynaecolo-
gists had pronounced as a fibroid a pelvic enlargement which
proved, on operation, to be a dilated tube filled with pus. He
asked Dr. Wylie if he had ever seen a case of pyo-salpinx in
which the tube was not adherent.
Dr. Wylie had seen only one such case ; as a rule, the tubes
were prolapsed and adherent posteriorly to the uterus or to the
pelvic floor. When the tubes were not prolapsed, their fim-
briated extremities were generally adherent to the uterus.
Dr. Lubk asked if it was necessary to remove both ovaries
and tubes in Tait's operation. He had left a tube and ovary in
two cases with subsequent bad results.
Dr. Wylie and Dr. Hunter had each had a similar experi-
ence, the disease being confined to one side.
Sept. 19, 1885.]
PHOCEEDINQS
OF SOCIETIES,
329
The Cftairm an asked Dr. Noeggerath whether it was com-
mon for only one tube to be involved in gonorrhoeal salpingitis.
Dr. Noeggerath replied that unilateral pyo-salpinx was
very rare, so that he could not say how often this condition
prevailed in specific cases. Reasoning from analogy, he could
see no reason why the disease should not be limited to one side,
since one epididymis frequently became involved as a result of
gonorrluea in the male, the other being spared. If there was
any doubt as to the existence of pyo-salpinx at the time of opera-
tion, lie believed that the surgeon was justified in squeezing out
a drop of the secretion of the tube from the fimbriated end. He
mentioned a case in which a woman had died of acute peri-
tonitis in twenty hours after receiving a severe mental shock.
On autopsy, both tubes appeared to be healthy, but a small
amount of sanguineous fluid could be pressed from them, which,
on microscopical examination, proved to be identical with simi-
lar fluid found in the pelvis. The contents of one tube escap-
ing into the peritoneal cavity had undoubtedly led to the fatal
result.
Dr, Wylie questioned whether the chronic peritonitis which
was present in cases of pyo-salpinx was due to the condition of
the tubes or vice versa; he thought that the diseased tubes
probably acted as inflammatory foci.
Dr. Ltjsk recalled a case of peritonitis developing on the
second day after a normal labor, and terminating fatally in
forty-eight hours. At the autopsy nothing abnormal was
found except an inflammatory condition of the tubes, the pre-
cise nature of which he could not recall; there was a possible
clement of latent gonorrhoea in the case, as the husband was
treated for a stricture and gleet before marriage.
Dr. B. F. Dawson also remembered a ea*e of acute peri-
tonitis in a young woman which terminated fatally, the tubes
heing found at the post-mortem to be full of pus.
Puerperal Septicaemia. — Dr. Wylie reported a case of
fever, which developed on the fifth day after delivery, which he
attributed to a diphtheritic process in the uterus, because regu-
lar pseudo-membranous masses came away during the injections.
He found that by using intra-uterine injections of sublimate
solution every hour the temperature could be brought down to
normal, but when the treatment was discontinued for two or
three hours it speedily rose to 104° F. He did not see why a
diphtheritic inflammation could not extend to the tubes.
Dr. Noeggerath believed that puerperal endometritis was
frequently diphtheritic in character. The elder Martin had
gone so far as to say that all these cases were diphtheritic, but
this was too sweeping an assertion. Dr. Noeggerath had ob-
served three cases in which pseudo-membranous casts of the
uterine cavity were discharged.
Dr. Wylie, in reply to a question from Dr. Hunter, said that
a solution of carbolic acid (1 to 60) brought away sloughs and
controlled the temperature much better than the sublimate
solution (1 to 5,000). Quinine had been used absolutely with-
out effect. He remarked in conclusion, with reference to the
objections to Tait's operation, that there were undoubtedly
many patients whose local condition improved so much under
treatment that an operation became unnecessary; he agreed
with Dr. T. A. Emmet that this experience was a very common
one in practice. It seemed to him, too, that it was often possi-
ble to remove the results of a previous peritonitis by appropri-
ate treatment without operations.
Dr. Noeggeratii insisted on a line being drawn between
perimetritis and parametritis, the presence of the latter condi-
tion being a distinct contra-indication to laparotomy. He
thought that the term " cellulitis " should be abandoned as a
relic of the old speculative pathology. Parametritis, as a rule,
was only present as a result of some lesion of the uterus (puer-
peral or otherwise), but not in disease of the tubes, the latter
being accompanied by perimetritis.
B. McE. Emmet, M. D.,
B. F. Dawson, M. D.,
H. C. Coe, M. D., ex officio,
Committee on Publication.
NEW YORK PATHOLOGICAL SOCIETY.
Meeting of September 9, 1885.
The President, Dr. John A. Wyeth, in the Chair.
Vesicular Mole. — Dr. H. J. Boldt presented the specimen,
which was principally interesting as illustrating the extremes to
which a patient might be reduced by a remediable condition.
The woman, who had been flowing profusely for several days,
had become very anaemic, and the pulse was almost impercep-
tible. A physician had employed a tampon, but without bene-
fit. Dr. Boldt found the os dilatable but not dilated. He at
once introduced a sponge-tent, dilated the canal, and found a
vesicular mole slightly adherent to the fundus and sides of the
uterus. The patient probably would have died within twenty-
four hours had the growth not been removed.
Coincidence between Vaccine Inoculation and the De-
velopment of Bone Abscess.— Dr. W. P. Watson presented a
girl five years of age who had always been well until two
years of age; the family history was also good. When two
years old the child was vaccinated, not by a physician, but by a
man who had vaccinated many other persons, so far as known
without injurious effects. In the case of the girl presented
two incisions were made below the deltoid, which bled pro-
fusely; it was not known whether the matter used was animal
or human. A few days after vaccination the mother noticed a
swelling on the outer aspect of the left forearm, which was
very much inflamed by the sixth day. A week later a swell-
ing appeared on the right arm in a similar position ; two weeks
later there was one over the left scapula, and two months later
one on the outer aspect of the right leg. Unhealthy pus dis-
charged from some of the abscesses for two years, and several
spiculaa of bone came from the sinus on the left forearm. The
sinuses were now entirely closed, but there was ankylosis at
the left elbow-joint. The axillary glands enlarged but did not
suppurate. The question arose, Was there any causative rela-
tion between vaccination and the development of the abscesses?
The mother very naturally attributed the trouble to vaccination.
Dr. Boldt asked whether the child might not have sustained
an injury after it had been vaccinated. [The mother replied in
the negative. There were an erysipelatous eruption and swell-
ing at the point of vaccination, which, however, were simulta-
neous in appearance with the swelling on the left forearm.]
Dr. Boldt then related the case of a child whom he had vacci-
nated, and in whose case multiple abscess developed. The
mother denied that any traumatism had occurred, but it was
learned that one day during her absence from the house the
child sustained a slight injury, which was followed by an ery-
sipelatous eruption and bone abscesses.
Idiopathic Nephritis in Infants.— Dr. J. Lewis Smith
presented some specimens from the body of a child which had
died, aged seven months. It had been fed by a wet-nurse, and
was seen by Dr. Smith only a few times during the course of
its illness. It had done well until nearly six months of age,
when the mother called attention to the fact that it had not
passed urine for some hours. Some sweet spirits of niter re-
stored the secretion. As bearing upon the (etiology, he said
there had not been any case of scarlet fever or diphtheria in the
institution recently. Five days later the urine was again sup-
pressed, but was restored by the same medicine. The child
330
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jock.,
then did well for about eleven days, when diarrhoea occurred.
After the second day the passages did not exceed four in num-
ber during the twenty-four hours, but the child did poorly, and
died September 1st. August 2d it had general convulsions
lasting five minutes. Following the convulsions there were
marked nervous symptoms lasting three days, and a constant
rolling of the head on the pillow afterward. During the last
two weeks of life the child had occasional cough. During
August the morning temperature was usually about 100° F.,
the evening temperature two or more degrees higher, the high-
est temperature reached being 106° F. The lesions of special
interest were in the kidneys. The organs were much enlarged ;
the cortex of the right kidney was thickened ; the pyramids
were congested ; the mucous membrane lining the calices'and
pelvis was deeply congested. The left kidney was intensely
congested, the pyramids and cortex being of one color. The
capsules were not adherent. The bladder showed catarrhal
inflammation. The urine found in the bladder contained mu-
cus, a large amount of albumin, and hyaline, granular, and epi-
thelial casts in abundance; mucous corpuscles and red blood-
corpuscles were present. Dr. Dana, who made the autopsy,
attributed death to acute nephritis. The case was interesting
as going to show that idiopathic nephritis might occur in the
young infant, a fact almost universally overlooked. [The speci-
mens were referred to the Microscopical Committee.]
Dr. Boldt had that day made an autopsy in the case of a
child which had had diarrhoea for three months. There was
suppression of urine the day before death. The temperature
reached 108-3°. Acute nephritis was found to exist. The child
was thirteen months old at the time of death.
Perforating Ulcer of the Duodenum. — Dr. Frank Fer-
guson presented two specimens, the first consisting of the duo-
denum perforated by an ulcer, the base of which was circular
and nearly an inch in diameter; the upper surface was triangu-
lar in form. The patient was a tailor, forty-five years of age,
who was unable to speak English or to give a full account of
his symptoms. It was learned, however, that he had been sick
for a month, complaining of pain in the stomach and constipa-
tion. On admission, he was emaciated, and the abdomen was
tender and retracted. He vomited several times. The tempera-
ture remained between 100° and 105°: the pulse was 82 ; the
urine was negative. Death took place two days after admission.
Dr. Ferguson remarked that he had seen three cases of perfora-
tion of the duodenum, and in all of them the peritonitis had
been of a type not easily diagnosticated. He thought the peri-
tonitis had probably existed a month and a half or two months.
Aspiration, perhaps, might throw some light on the diagnosis.
The danger of perforating the intestine with the needle he
thought was not great.
Cardiac Dilatation and Hypertrophy; Perforation of
the Inter-ventricular Septum; and Vegetations on the
Aortic, Tricuspid, and Pulmonary Valves.— The second
specimen presented by Dr. Ferguson was the heart of a boy,
thirteen years of age, who had probably had rheumatism. He
also suffered from difficult breathing and slight general ana-
sarca. The sternum and the jugular veins were prominent;
the cardiac area was increased ; the apex beat could not be
felt; there was a distinct epigastric impulse. There was a loud
blowing thrill in the seventh intercostal space, oil a line with
the nipple, transmitted to the left; in the second intercostal
space, just to the right of the sternum, was a double systolic
murmur, transmitted upward. Before death the respiration and
the pulse became very rapid. At the autopsy the lesions of
chief interest were found in the heart. It was dilated and
slightly hypertrophied, and there were vegetations on the
aortic, the tricuspid, and the pulmonary valves. There was an
opening through the inter-ventricular wall, and it was not im-
probable that vegetations from the left side of the heart had
found their way through this opening into the right side. At
any rate, vegetations in the right heart were seldom seen.
There was no history of embolism.
OBSTETRICAL SOCIETY OF PHILADELPHIA.
Meeting of September 3, 1885.
The President, Dr. B. F. Baer, in the Chair;
Dr. W. II. H. Githens, Secretary.
Ovarian Cystoma complicated with Peritonitis and
Phlegmasia Alba Dolens ; Double Ovariotomy.— The Presi-
dent read the following report of a case:
" Mrs. M., aged thirty-one, has been a widow nine years. She had
one child ten years ago, and had enjoyed good health until about three
years before I saw her. At that time she observed that her abdomen
was increasing in size. This gradually progressed for eighteen months,
when she was large enough to attract the attention of her neighbors.
After this the growth remained almost stationary, and did not affect her
general health until the latter part of March of the present year, when
she was suddenly seized with pain in the left iliac region. The pain
was acute and radiating in character, extending principally down the
anterior portion of the left thigh. She attributed the attack to an un-
usual exertion. Although she made an effort to continue her avocation
— that of a seamstress — she was compelled to give up and send for her
physician, my friend, Dr. John R. Haney, of Camden, N. J. When Dr.
Haney first saw her, her abdomen was very tender over its entire sur-
face, purple from congestion, greatly distended, and tympanitic in its
upper, but dull in its lower, portion. She was suffering great pain, and
had constant nausea and vomiting; her skin was hot, pulse 120, and
temperature 130° F. From the history, symptoms, and physical signs
elicited, the doctor diagnosticated ovarian cystoma, with supervening
peritonitis. He administered quinine per rectum and morphine hypo-
dermically, and employed counter-irritation over the abdomen. Within
a week the patient appeared to be better, when, through the kindness
of Dr. Haney, I first saw her. The tympanites had disappeared, and
the pain was nQt so severe, but the abdomen was still very tender on
pressure, especially in the left iliac and right umbilical regions ; her
features were drawn and flushed, and presented an anxious expression;
her tongue was dry and heavily coated, her pulse quick, and her tem-
perature 102° F. She lay quietly in the dorsal position, with her thighs
flexed. The abdomen was as large as at full term of gestation, and
was projecting. It was dull on percussion everywhere, except along
the line of the colon and in the epigastrium, and there was evident
fluctuation. The uterus was retroverted, not freely mobile, and very
tender on pressure on the left side. Above and upon it could be felt
the lower border of the circumscribed growth which occupied the ab-
dominal cavity. I fully agreed with Dr. Haney 's diagnosis of ovarian
cyst, complicated by peritonitis. As she seemed to be somewhat bet-
ter, I advised a continuance of the treatment as previously pursued,
with the hope of obviating the necessity of ovariotomy during the un-
favorable condition in which she then was. The peritonitis continued
to improve slowly, but a new trouble presented itself in a very painful
swelling of the left lower extremity. This continued until the limb was
greatly increased in size. Its temperature was much higher than that
of its fellow, which seemed to be in a normal condition. She now re-
quired large doses of morphine to relieve her pain, and she was losing
flesh and strength. She still had nausea, and took scarcely any nour-
ishment. Her temperature and pulse had again risen to the highest
point noted. Both she and her friends were willing and anxious that
we should do something more radical than simply wait for a more
favorable condition for operating if we deemed it proper. I believed,
from the symptoms and physical signs, that the inflammatory action
was external to the cyst and not within it, and for that reason decided
to wait for a subsidence of the acute symptoms, which I rather confi-
dently expected. At the same time I held myself in readiness to oper-
ate at once should the patient not improve or become worse. The next
Sept. 19, 1885.]
PROCEEDINGS OF SOCIETIES.
331
day she showed signs of slight improvement. The treatment, both
local and general, was continued. The acute symptoms gradually sub-
sided to those of a subacute condition. The temperature had decreased
to 101° F., the pulse was 100, but weak. She was still unable to retain
food, and was extremely weak. I advised further delay. But she did
not improve much after this, her temperature and pulse remaining about
the same as that noted above. Her stomach had regained its power to
a slight degree to retain and digest liquid food. She had now been
confined to her bed more than two months. Her left leg was power-
less. There had not been the slightest improvement during the two
previous weeks. We therefore decided to remove the tumor.
"Operation. — June 19, 1885, assisted by Dr. J. R. Haney, Dr. W. A.
Davis, and Dr. H. M. Christian, and in the presence of a section of the
class from the Polyclinic, I made an incision three inches in length
down to the peritonaeum, and then checked the haemorrhage, which
was free, with clamp forceps. I next very carefully incised the peri-
tonaeum and found, as I had expected, that it was closely united to the
cyst-wall. These adhesions of the cyst to the peritonaeum were univer-
sal, and it required careful and patient manipulation to separate them.
The parts were exceedingly vascular and the haemorrhage was profuse.
After separating it as far as possible, I tapped the cyst and allowed
the contents, which were semi-liquid and chocolate-colored, to drain
away. I next closed the puncture made by the trocar, and then com-
pleted the separation of the cyst from its adhesions and removed it.
As there was a very general and free oozing of blood from the broken
vessels, I introduced a number of large, flat sponges, and spread them
over the bleeding surface. An assistant now made firm pressure upon
the external surface of the abdominal walls, while I ligated the pedicle
and removed the tumor. The cyst had developed in the left ovary, and
the pedicle was slender, not unusually vascular, and of good length.
The right ovary was diseased, containing a number of small cysts, and
was of double the normal size. I removed it also. Examination now
showed that the haemorrhage had almost ceased, but there were still a
number of points from which blood flowed. The peritonaeum was in-
tensely injected, and I disliked very much to pick up bleeding points
for fear of making the haemorrhage worse. I therefore reapplied a
large flat sponge, and had firm pressure again made from without,
while I proceeded to place the sutures for the closure of the incision.
I then removed the sponge and found very little blood upon it. I re-
placed it by a long narrow strip of sponge, which I allowed to project
from the lower angle of the wound, and then again cleansed Douglas's
cul-de-sac and other dependant portions of the peritoneal cavity, after
which I quickly tied the sutures from above downward, removing the
long sponge through the lower angle of the wound before I had en-
croached so closely upon it as to compress it in its removal. It was
only slightly stained. I quickly applied the external dressing, making
an unusual amount of pressure by cotton and bandage. The operation
was finished, but the patient bore it badly. Her extremities were cold
and purple, her face livid, and her pulse very weak. Stimulants hypo-
dermieally, and the application of external heat, which were begun
during the operation, were continued after she was returned to bed.
She remained in an almost collapsed state for many hours, but grad-
ually reacted, and the next morning was in a fair condition. Her tem-
perature was lower than it had been for weeks; pulse 112, but weak;
stomach quiet, no pain, no tympany. She had taken an occasional
small piece of ice, but nothing else except the morphine since the
operation.
"21st. — Temperature 102°, pulse 120. Slight pain and tenderness
in the left iliac region. She had been very weak and faint during the
night, for which brandy had been administered in repeated small doses.
The swelling and pain in the limb had diminished ; she had not vom-
ited since the operation, and felt hungry. Ordered a teaspoonful of
milk every second hour.
" 22d. — Comfortable and doing well. Temperature 99"4° ; pulse 90
and strong ; slight metrostaxis ; passed flatus per rectum. Milk in-
creased to a tablespoonful and retained.
" 24th. — Temperature 99°, pulse 85. General condition greatly im-
proved ; no pain, no tympany. Examined the wound and found it
united throughout ; removed the sutures.
"25th. — Doing well, and is bright and cheerful. She has taken
nearly a quart of milk during the last twenty-four hours, and digested
it.
"30th. — She has been gradually improving. Temperature normal,
pulse 95 ; bowels moved to-day. She is taking solid food and expresses
herself as feeling quite well. Limb improving. She can now move it.
"July 12th. — Sat up to-day for the first time, the twenty-second
after the operation.
"August 30th. — A note received from Dr. Haney to-day informs me
that Mrs. M. is going about attending to some of her duties, but that
she has not yet regained her strength fully, and that her limb is still
weak.
"The recovery of this woman under the forlorn circum-
stances just narrated is certainly a great triumph for our art;
but the case serves a better purpose in forcibly illustrating the
danger of deferring operative interference in ovarian cystoma
simply because the patient is comfortable and suffering no in-
convenience from the presence of the tumor. The subject of
an ovarian tumor is in constant danger of injury from slight
causes which may produce such changes in the tumor as to ren-
der what might have been a simple and safe operation one of
extreme hazard. This had been a simple, slow-growing cyst,
and had not markedly affected the health during its three years
of existence; yet it suddenly became inflamed and the patient
narrowly escaped death as a result. The case furnishes a strong
argument in favor of operation as soon as the disease is diagnos-
ticated. Of course there are qualifications, and each case must
be decided on its own merits; but the rule that an ovarian tu-
mor should be removed as soon as it is known to exist is the
only safe one to follow."
Polycystic Ovarian Tumor; Double Ovariotomy. — "As
a striking contrast to the case just related, and to show the
value of the principle enunciated," continued the President, "I
will report the following case:
"A. R. was sent to me August 5, 1885. She was nineteen years of
age ; single. Puberty was established at sixteen, and she had menstru-
ated regularly until six months previously. She then without cause, so
far as she knew, began to flow more freely at her periods and they con-
tinued longer. About the same time she noticed a small lump in the
right iliac region. This increased in size so that soon the entire hypo-
gastrium was distended, and when I first saw her she was as large as a
woman at the eighth month of gestation. Her face showed marked
signs of emaciation and pallor, and the drawn, anxious expression of
ovarian cystic disease. She was then having a profuse metrorrhagia
every two weeks. She had not suffered any pain, and up to within a
few weeks very little inconvenience, except from the frequent metror-
rhagia. During the last month, however, her health had been failing,
she had lost flesh, had a weak, languid feeling, and suffered much from
the weight of the growth. Physical examination in the dorsal position
revealed a projecting, slightly irregular abdomen, larger on the right
side, dull on percussion over the entire anterior surface, but resonant
along the line of the colon. Palpation showed imperfect fluctuation
and several firm, irregular masses within the abdominal cavity. The
vagina was virginal, the cervix uteri was pointing forward, the body of
the uterus retroverted, the whole organ enlarged and soft. It was only
slightly movable independently of the tumor. The sound gave a meas-
urement of three inches.
" I diagnosticated polycystic disease of the right ovary, and advised
immediate operation. Six days afterward, on August 11th, she entered
my private hospital, and on the 13th I operated, with the assistance of
Dr. H. M. Christian and Dr. J. N. Richards. I made an incision two
inches and a half in length and came upon the surface of the tumor,
which presented the white, glistening, nacreous appearance especially
common to thick-walled polycysts. I tapped it with Hodge's trocar.
The contents were so thick that they flowed very slowly, and it was
necessary to puncture several smaller cysts, which was done without re-
moving the instrument. Even then the mass did not collapse much,
because of a large number of young or child-cysts. After closing the
puncture I enlarged the incision to three inches, but I had considerable
332
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jouk.,
difficulty in removing the tumor. It was necessary to make firm trac-
tion with rotatory movements while Dr. Christian exerted a counter-
force and pressure through the abdominal walls. Fully ten minutes
were occupied in extracting the tumor after it was tapped, hut I was
rewarded with an incision that looked so small that it seemed almost
incredible that this large mass had passed through it. There had not
been a single adhesion, but the pedicle was short, thick, and vascular.
I tied it with Tait's Staffordshire knot, cut the tumor away, and dropped
the stump. The tissues of the left ovary were found to be entirely dis-
organized and degenerated into a cyst as large as a walnut. This I also
removed. The uterus presented a very vascular appearance and was
somewhat enlarged. After assuring myself that the peritoneal cavity
was entirely free from any foreign matter, I closed the incision, dressed
the wound, and returned the patient to bed. Her temperature was
normal, and her pulse 96. There was no pain, but, as she felt a little
sore and restless, a quarter of a grain of morphine was given hypoder-
mically, and she took small pieces of ice for thirst.
" lJfih. — 8 a. m. Temperature 99°, pulse 84. Had passed a good
night. At 1 p. m., twenty-six hours after the operation, milk in tea-
spoonful doses was allowed, and water when she desired it.
"15th. — Metrostaxis began this morning.
''18th. — Union complete ; removed the sutures. Her recovery was
uninterrupted. She sat up for a few minutes on the eleventh day and
went home, eight miles, in a carriage on the eighteenth day after the
operation. To-day she sent a request to be permitted to go out, because
she was feeling so well.
" Certainly nothing could have been gained by procrastination in
this case."
Dr. Goodell congratulated the president on the good result
obtained in such a serious case as that first reported. Great
care as to asepsis should be observed in these cases. In one of
his cases of septicaemia before the operatioo, after complete
union had been secured, after the stitches had been removed,
and after the patient was up, an abscess was observed forming
in the line of union and was very persistent. Finally, after
careful search, a ligature which had been tied around the pedi-
cle of one of the ovarian cysts was found and removed. Subse-
quently the other appeared, and, after its removal, the abscess
healed. He did not like to remove the stitches so early as the
president removed them ; and he reminded him of a case in
which he had assisted him (Dr. Goodell). The operation was
performed on December 5th. Convalescence was rapid, and
the patient was so impatient to be home on Christmas that she
could not be restrained, and on the nineteenth day after the
operation she took the cars for home. The train was derailed
and the jolting caused the cicatrix to open. The physician who
was called in closed it immediately and the patient recovered
In another case a cough caused the wound to burst open and
reveal the bowels after the stitches had been removed. This
patient also recovered. For these reasons he never removed
the stitches before the eighth day and not until the bowels had
been opened. The speaker inquired of the president what his
method was of closing the opening in the cyst after it had been
tapped preparatory to its removal from the ahdominal cavity.
Did he employ pressure forceps? What method did he use of
dressing the abdominal wound?
The President closed the cyst puncture with Wells's clamp-
forceps when the cyst-wall was strong enough. In some cases
he stitched up the opening, or tied a string below it when the
cyst-walls were loose and soft. He closed the external wound,
as he had been taught by Dr. Goodell, with silk sutures, and
dressed it with salicylated or absorbent cotton, adhesive strips
to hold the cotton in place and take the strain off from the
stitches, and over all a bandage. He removed the sutures on
the fourth or fifth day in order to avoid the danger of pus form-
ing in the suture-tracks, as had sometimes occurred when he
had allowed them to remain as long as eight days.
A Uterine Dilator.— Dr. Goodell exhibited his improved
uterine dilator. He said that the main difficulty in the opera-
tion for the rapid dilatation of the cervical canal lay in the lia-
bility of the blades of the instrument to slip out. This he had
in a great measure overcome by having shallow grooves cut
into them. Into these grooves the tissues sank, and the result-
ing friction kept the instrument in place. Since he had called
the attention of the society to .his instrument, not quite a year
ago, he had performed the operation forty-one times for dys-
menorrhea and sterility, making in all two hundred and nine
such cases. In not a single instance had dangerous symptoms
followed, and the average of success was a very large one. He
had become firmly convinced that for dysmenorrhea and sterili-
ty the operation of rapid dilatation of the cervical canal would,
except in some very rare cases of stenosis of the os externum,
wholly supersede the cutting operation, the use of tents, and
slow dilatation by any means whatever ; for by the former
not only was the measure of success far greater, but the danger
from inflammation was very much less. He dilated the parts
from three quarters of an inch to one inch and a quarter as
measured off by the register in the handles, watching the cervix
carefully to see what strain it could bear. His instrument could
be opened to the width of an inch and a half, but he resorted
to that extreme divergence only when wishing to introduce his
finger for diagnostic purposes. This he could not ordinarily do
unless the parts were relaxed from haemorrhage. Usually, how-
ever, when suspecting the existence of a polypus, he did not
find it needful to pass in his finger, for after a moderate dilata-
tion he introduced a fenestrated forceps and opened it at hap
hazard. In this manner he had repeatedly caught and twisted
off a polypus without knowing it was present, the subsequent
removal of the growth through the os uteri being the most
difficult part of the operation.
The President had been strongly impressed, by the case of a
lady whom he had delivered to-day, as to the advisability of en-
tirely giving up division of the cervix. A year and a half ago
he had slit up the cervix posteriorly, and to-day he had felt very
anxious during the first stage of labor as to the probability of
laceration of the uterus starting from the seat of the former
operation. The anterior lip was very long, coming down under
the bubes, and the posterior lip could not be felt. The case
would be reported in full.
When the uterus contained a polypus the continued haemor-
rhages reduced the contractility and a single dilatation would
sometimes enlarge the os sufficiently to admit the finger or for-
ceps ; but, if the uterus was healthy, it contracted immediately
after the withdrawal of the dilator. He could not recall an in-
stance of inflammation following rapid dilatation. Sterility of
long standing was seldom cured by dilatation or any other
means.
Dr. C. M. Wilson had seen recently, in the practice of Dr.
Ellwood Wilson, a uterus the cervix of which had been divided
bilaterally some years ago. The operation had resulted in the
development of the symptoms peculiar to a bad laceration of
the cervix, with ectropion. Trachelorrhaphy was performed
by Dr. Agnew, with complete relief to the patient. Dr. Wil-
son mentioned this case to call attention to the change in opin-
ion and practice since Emmet proposed his operation.
Dr. Longaker inquired as to the prevention of slipping of
the dilator, and called attention to the original method of
pressure over the fundus of the uterus.
Dr. J. G. Allen had performed rapid dilatation over seven-
ty-five times, and had never seen any bad results from the
operation. The blades of his instrument diverged as they sepa-
rated, and there was then no disposition to slip out. The blades
were more curved than in Dr. Goodell's instrument. He thought
Sept. 19, 1885.]
PROCEEDINGS OF SOCIETIES.
333
that an advantage in holding the instrument in place; the han-
dles were turned up so as not to touch the bed or table.
Dr. Goodell preferred the slight curve, so that in flexion of
the uterus he could introduce the dilator with its curve reversed
to the bend in the womb, and, by opening the dilator in that
position, rectify the flexion of the organ. He preferred parallel-
ism of the blades because the stenosis of the cervix was great-
est at the external os, and there was no need of dilatation
above the internal os. lie considered it dangerous to press the
fundus of the uterus down while using the dilator, for fear of
wounding or even penetrating the tissues, and he used a strong
tenaculum to hold the organ ; but, since he had got Mr. Gemrig
to roughen the blades by grooves, he had not been annoyed by
the slipping of the instrument. He rarely found it necessary to
separate the blades more than one inch, but he sometimes did
so to the extent of one inch and a half, especially when he
wished to introduce his finger into the uterine cavity.
Parovarian Cysts. — Dr. Goodell exhibited two specimens.
In each case the cyst was so detached from the ovary that the
former could have been taken away without injury to the ovary.
He was greatly tempted to practice conservative surgery in these
cases, and leave the ovaries untouched. ; but, on account of ap-
parently incipient cystic degeneration, they also were included
in the ligature and removed. Both these patients were oper-
ated on in his private hospital, and both had recovered. In his
experience the removal of parovarian, or of broad-ligament,
cysts was one of the most successful of operations. Out of a
large number which he had performed he could recall but a
single fatal case, and in that the result seemed hardly due to the
operation. The lady lived in a distant city, and he did not see
her after the operation, which was a very easy one. At the
end of a week the bowels were moved, the stitches removed,
and everything gave promise of an unusually prompt convales-
cence. On the twelfth day, however, she was seized with un-
controllable vomiting, and she died on the seventeenth day.
Six months previously she had had an analogous attack of vom-
iting, from which she barely escaped with her life. Thus far
this year he had had eighteen ovariotomies, and this was the
only fatal case among them.
Dr. Montgomery wished to ascertain the opinion of the
society as to the advisability of removing the second ovary
when in an operation for the removal of an ovarian cyst the
other ovary was found to be slightly diseased. In his first
ovariotomy, performed in lS1?^ the second ovary was found to
contain numerous small cysts; it was not removed, and the
patient had since been twice pregnant and there had been no
appearance of another tumor, nor any symptoms referable to
the remaining ovary. If the climacteric had been passed there
would be no question about it.
The President inquired if tapping ever cured parovarian
cysts. It was formerly reported as a means of cure. Did they
always return after tapping? Would Dr. Goodell recommend
tapping in undoubted parovarian cyst? He himself felt strongly
inclined toward abdominal section in all cases. He thought the
second ovary should be removed when it was not healthy, as
the idea of a second operation was very depressing to a patient.
Dr. Montgomery knew of one instance of parovarian cyst
which had been tapped and had refilled seven times. It was
finally removed by him by pulling out the cyst, as, on opening
the abdomen, he found the tumor universally adherent. Only
one ligature was required — viz., on the stump of an enlarged
ovary which bulged prominently into the cyst cavity.
Dr. J. G. Allen considered that, as an ovary somewhat dis-
eased might give rise to a pregnancy, it should be left. We
knew too little about the probability of the development of such
small cysts into large ones. Until we had certain data on the
subject it must be considered a case of want of information and
knowledge.
Dr. Parish was in accord with Dr. Allen as to the want of
knowledge, ne had seen diseased ovaries containing numerous
small cysts in many autopsies, and there had been no symptoms
during life to excite a suspicion of their existence. The exist-
ence of minute cysts could not be considered as proving any
liability to the production of large ones. If the second ovary
contained a cyst as large as a partridge's egg he would remove
it, but if numerous cysts as small as split peas were present he
would not. The possibility of conception should be considered
as well as that of a cyst.
Dr. Goodell acknowledged the truth of the points made by
Dr. Allen and Dr. Parish, and he believed that he had repeat-
edly removed the second ovary unnecessarily. Yet the history
of his own ovariotomies showed a return of the disease in the
remaining ovary in about two per cent., and he thought he
erred on the safe and right side. The social conditions of the
patient would always have a great weight with him. If an heir
was wanted or the patient was young, he would leave a sus-
picious-looking ovary, or try to remove the diseased portion of
it. But in the majority of his cases where there was any doubt
he removed the ovary. Of course, under such a rule, he must
remove ovaries which might never give any trouble in the fu-
ture. But the mental agony of women when informed that the
operation must be performed a second time upon them, and, on
the other hand, the great joy and satisfaction of patients when
assured, after the close of an operation, that both ovaries had
been removed, had convinced him that, other things being
equal, it was better to remove the second ovary.
As to the cure of parovarian cysts by tapping, his own ex-
perience was not sufficient yet to decide absolutely. He would
advise the radical operation, but if the patient, after understand-
ing the liability of return, wished it, he would tap, as there was
but little danger from tapping such cysts. A patient was tapped
by Dr. Atlee some twenty years ago; five years afterward the
cyst filled and was tapped by the speaker. It then partly re-
filled and so remained for a long while ; the fluid then was gradu-
ally absorbed and never returned. He had had besides this
one two cases in which he tapped, one five years ago and the
other three years ago, and there had been no return whatever of
the fluid. On the other hand, he had had two or three cases in
which the cyst burst spontaneously several times and yet re-
filled invariably. The rupture was followed immediately by
some collapse and pain, and subsequently by an excessive secre-
tion of urine, with complete subsidence of the tumor. He had
also heard of several cases of rupture, hut, so far as he had
learned the history of such cases, the cyst had always returned.
The reports of the cure of ovarian cysts by tapping and injection
of tincture of iodine must be true only of parovarian cysts.
Dr. Harris knew of a case of parovarian cyst in which four-
teen years had elapsed between the tapping and the subsequent
refilling.
Bromide of Ethyl.— Dr. E. E. Montgomery read the fol-
lowing supplement to his paper : " I read a paper on bromide of
ethyl as an anaesthetic in labor before the April meeting of this
society. Although I did not attempt a history of the early ad-
ministration of the drug, subsequent investigation has shown
me that I did Dr. L. Turnbull injustice in not mentioning that
to him we are indebted for the revival of this agent and its first
use in this country. In following the German literature, by
wThich I was led to use this drug in labor, 1 ascribed its first
obstetrical use to Lebert, of Paris. The first case in which he
used it was for the application of the forceps, and occurred in
March, 1881 ; but a paper published by Dr. Turnbull (' Mod.
Bull.,' June, 1880) shows that he had then used it in a second
334
MISCELLANY.
[N. Y. Mud. Jooh.,
case of labor, and spoke in higli terms of its peculiar advantages.
Dr. H. Augustus Wilson had used it iD labor prior to August 7,
1880, when he published an article upon this drug ('Med. and
Surg. Rep.,' August 7, 1880). It becomes quite evident that
the first obstetrical trial of this agent was made in this city, and
the priority lies between the gentlemen named. Various mix-
tures of the ethyl have been advocated in labor and minor sur-
gical operations. Booth, of Ohio (' Therap. Gaz.,' 1884-'85, p.
159), recommends alcohol two parts, chloroform and bromide
of ethyl, each one part. W. A. By id, of Quincy, 111. {Hid.,
March, 1884), has used bromide of ethyl one part, chloroform
three parts, alcohol four parts, in some ninety-eight cases with-
out a single unpleasant symptom. It has not everywhere re-
ceived the same condemnation that is shown by the hesitancy
to use it in this city. In spite of the bad name given it by two
deaths under its use and the apparently dangerous symptoms
induced by experiments upon the lower animals, its use has
been revived by Chisolm ('Maryland Med. Jour.,' 1882-'83, ix,
388) and Prince ('St. Louis Med. and Surg. Jour.,' 1883, xiv,
297), who strongly urge its use in minor operations, and pre-
liminary to the administration of ether. The last named has
reported five hundred cases in which it was used without a
single unpleasant symptom. A leading article in the ' Thera-
peutic Gazette,' June, 1885, advocates a redistillation of a mix-
ture of bromide of ethyl and olive-oil as a valuable and safe
anaesthetic in labor. These facts are referred to simply to in-
duce the profession to give this anaesthetic a fair trial in amelio-
rating the terrible suffering of natural labor."
Fibroid Polypus of the Uterus. — Dr. Montgomery exhib-
ited a uterine fibroid polypus. Miss R., aged thirty-eight years,
began to menstruate at seventeen years. The flow was regular,
quite free, lasting a week, and was attended with pain the first
three days. Ten years ago she had a haemorrhage, and subse-
quently several such attacks. Two years later she had a severe
haemorrhage followed by a bloody discharge continuing several
months, since which time she had never been regular. The
flow would occur too frequently, be very profuse, and be at-
tended with pain and loss of flesh. The symptoms had been
more marked during the last year. At one of the hospital
clinics, some years ago, the difficulty was ascribed to anteversion
of the womb. Dr. Bournonville examined her three weeks ago,
diagnosticated the condition fibroid polypus, and referred the
case to the speaker for treatment. She was quite pale, her lips
were bloodless, and she complained of pelvic pain and of a con-
stant bloody discharge, which amounted to haemorrhage upon
the slightest exertion. The vagina was dilated by a tumor of
the size of an orange, about the pedicle of which could be felt
the neck of the uterus. The finger passed into the os and about
the tumor without difficulty. Every examination was followed
by severe haemorrhage. The pedicle was cut through by means
of the wire ecraseur, and the tumor removed by means of a
polypus forceps. Considerable haemorrhage followed its re-
moval. As this was not controlled by applications of hot
water, a tampon saturated with a solution of subsulphate of
iron was introduced. This was renewed on the second day.
On the fourth her temperature ran up to 103°, she had a chill,
and pains in various parts of her body. These symptoms van-
ished under the use of quinine, digitalis, and opium. Five
weeks after the operation she appeared much improved, had
had no bleeding, her appetite and strength were greatly in-
creased, the uterus was normal in size, the cervix was still
dilatable and would admit the finger with pressure, and the
cervical membrane was in good condition. The tumor was of
the size of an orange. The mucous membrane of the lower sur-
face was ulcerated, so that vessels were ruptured, allowing
haemorrhage on any exertion. The case was of interest from
the long continuance of the haemorrhage, and illustrated the
importance of early and careful examination of the cavity of the
uterus in cases of protracted haemorrhage.
Dr. Goodell seldom used the wire now for the removal of
uterine polypi. He preferred traction with twisting or enucle-
ation by the finger. There was less bleeding, and he was
afraid of " cupping" of the fundus uteri and its injury by being
included in the wire loop. lie had made traction with the ob-
stetric forceps, and enucleated tumors so large as to rupture the
perinaeum even after lateral incisions had been made in the
labia. He had partially inverted the womb, enucleated the
tumor, and then restored the organ to its proper form. The
tumor sometimes occluded the os, and foetid pus from necrosis
of the growth was imprisoned above it, giving rise to a suspicion
of cancer.
The President thought Monsel's solution might havecaiiM.d
the high temperature. Vinegar would have been a better
haemostatic, and it was also an antiseptic. From the appearance
of the specimen a portion of the adventitious growth seemed
to have been left behind, and it would be interesting to know
the history of the stump.
Dr. Parish had removed many fibroids of various sizes, and
sometimes with degenerated tissues and noisome odors. The
rapid recovery of Dr. Montgomery's patient was remarkable.
It was much to be regretted when any portion of the tumor
was left, as necrotic change was rapid and decided in such tis-
sue, and there was danger of blood-poisoning. The pedicle,
however, generally shrank and disappeared.
Dr. Goodell remarked that this tumor appeared to be ses-
sile, and had been wholly removed. The pedicle proper was
usually simply mucous membrane, without adventitious tissue^
and it made very little difference if some of it was left behind,
as it shriveled away and was absorbed.
Dr. Allen had sometimes regretted that he was compelled
to leave a portion of pedicle or tumor in the uterus, but he had
never seen any bad consequences follow it. He preferred vine-
gar to iron as a haemostatic, and considered it as good an anti-
septic as carbolic acid.
Dr. Montgomery remarked that the wire had evidently
brought away all the tumor. There was no evidence of any
remnant on examination to-day. In one case a portion of tumor
or pedicle had been unavoidably left, and he had removed it
some time afterward by means of a tenaculum. He wounded
his finger in doing so, and suffered from septicaemia. The
woman had an attack of cellulitis.
The International Medical Congress. — In its September issue, pub-
lished before the recent meeting of the committee in New York, the
" American Practitioner," of Louisville, says :
"When the handful of agitators who made all the commotion and-
din at New Orleans in May meets in New York, on the third of this
month, they will assume a very different tone from that they used at
Chicago in June. Much of their zeal will have been quenched. The
wet blanket which public opinion has wrapped about them will have
cooled their enthusiasm, while the almost universal condemnation of
their movements, both at home and abroad, has demoralized the leaders
of the ill-timed and ill-starred revolution and reduced their followers to
a mere corporal's guard.
" To speak without mincing words, failure was written all over the
new committee from the very start, and it already totters to its fall.
Even though it were vouchsafed the wisdom to undo all it did at Chi-
Sept, 10, 1885.]
MISCELLANY.
335
cago, the public mind has been so exasperated by its behavior that noth-
ing short of an unconditional surrender would now be entertained. The
feeling of the profession demands this, nor will it accept less. Let the
agitators make no mistake on this point. They must lay down their
arms and submit, with what grace they can, to be marched to the rear.
Nothing short of this will be received as a settlement. This, and this
alone, will open the only road that will lead to an International Con-
gress in 1887.
" The National Association made an egregious blunder when it ap-
pointed at New Orleans a new committee. It blundered again in the
selection of the men who composed the committee. And the commit-
tee, true to its origin and its instincts, has blundered from that day to
this. Conceived in error, all its steps have been marked by unwisdom
and stained by selfishness. Fortunately for the best interests of the
profession, not only in this country but throughout the world, its mis-
chievous career is fast drawing to a humiliating close. Before these
lines are read the committee will have realized that ' consequences are
unpitying.'
" The leaders were bold enough when precipitating this deplorable
imbroglio, and remained deaf to all reason. Their ears have been made
to hear since that time. The voice of the profession has reached them,
and not one of them all is so daft but he realizes that an overwhelming
majority of the forty thousand physicians in the United States declines
to lend countenance or support to the new committee or its schemes.
The more thoroughly the committee digests this fact the better will it
be all round. For what manner of congress would a congress be with-
out representatives ? "
Commenting upon what is known of the action taken in the com-
mittee meeting lately held in New York, the " Medical News," of Phila-
delphia, says :
" Without wishing to prejudge the work of the committee, we can
not refrain from giving voice to the regret that will be universally felt
that no effort was made at the meeting to harmonize the grave differ-
ences which exist in the profession, and that the expressed views of the
European members of the Congress were not deemed of sufficient im-
portance to be accorded consideration."
The "Journal of the American Medical Association" publishes an
official report, signed by Dr. Shoemaker, of the doings of the enlarged
committee at its sessions in Chicago and in New York. The report in-
cludes the rules adopted, the first of which reads as follows : " The
Congress shall consist of members of the regular profession of medi-
cine, and of such other scientific men as the Executive Committee of
the Congress may see fit to admit, who shall have inscribed their names
on the register and shall have taken out their tickets of admission."
The report contains the following statement : " Lists of vice-presi-
dents, secretaries, and councilmen for each section were named by the
Committee of Arrangements, but, as it was not practicable to ascertain
at once who would accept the places assigned them, or who of those
"who had been announced in the medical press as declining to accept
positions before the present rules and organization had been adopted,
as given heretofore, might wish to withdraw such declination, the final
adjustment of these offices was referred to the Executive Committee of
the Congress, and all correspondence in relation thereto was transferred
to the Secretary-General of the Congress."
Editorially, the same journal, after referring to the action taken at
the New York session, asks : " May we not hope, therefore, that a spirit
of harmony will be fostered, and that all who hold the honor and inter-
ests of the profession above all personal considerations will cease to dis-
cuss the past, and cordially co-operate in making the International Con-
gress of 1887 an honor to our country and a benefit to the profession
of the world ? "
The American Gynaecological Society will hold its tenth annual
meeting at the Columbian University, in Washington, on Tuesday,
Wednesday, and Thursday, September 22, 23, and 24, 1885. Among
the papers announced to be read are the following: "The Natural Hy.
giene of Child-bearing Life," by Dr. S. C. Busey, of Washington ; " Re-
marks on the Use of Tarnier's Forceps," by Dr. Ellwood Wilson, of
Philadelphia ; " Facial Paralysis in the Infant from the Use of the Ob-
stetric Forceps," by Dr. T. Parvin, of Philadelphia ; " The Genu-pec-
toral Posture in the Prolonged Nausea and Vomiting of Pregnancy,
with Cases," by Dr. H. F. Campbell, of Augusta, Ga. ; "On Two Rare
Cases in Abdominal Surgery " (the President's Address), by Dr. W. T.
Howard, of Baltimore; "The Care of the Pennaeum during Labor," by
Dr. T. A. Reamy, of Cincinnati ; " Report of a Case of Cajsarean Opera-
tion," by Dr. E. W. Jenks, of Detroit; "Puerperal Diphtheria," by
Dr. H. J. Garrigues, of New York; "A Modification of Emmet's Cer-
vix Operation in Certain Cases, with a Case," by Dr. R. S. Sutton, of
Pittsburgh ; " Inflammation of the Parotid Glands after Ovariotomy,"
by Dr. William Goodell, of Philadelphia : " A Study of an Unusual
Type of Puerperal Fever," by Dr. Fordyce Barker, of New York ;
" Peristalsis of the Genital Tract," by Dr. J. R. Chadwick, of Boston ;
" Four Cases of Oophorectomy, with Remarks," by Dr. Joseph Taber
Johnson, of Washington. Members of the profession are cordially in-
vited to attend the meeting.
An Important Discovery concerning the Venous Circulation in
the Fingers. — Until now the injection of minute venous radicles in a
manner calculated to be of practical service has been impossible, chiefly
on account of the resistance of the valves. It is true that injections
could be make to reach the veins through the arteries, but in that case
both arterial and venous vessels were filled with a material of the same
color, so that the two were with great difficulty, if at all, to be distin-
guished from each other. M. Bourceret has recently overcome the diffi-
culty of injecting the veins in a direction contrary to that of the blood,
current, and has thus already been able to demonstrate some striking
facts. As described by M. Poirier, in a recent issue of the " Progres
medical," M. Bourceret's process is as follows : The part to be injected is
kept in a warm bath (from 104° to 113° F.) for five or six hours. A color-
less injection is then slowly and steadily thrown into the main artery. It
passes into the subcutaneous veins, and the injection is stopped as soon
as those veins appear well defined under the skin, and before they are
distended. The largest of the superficial veins is then punctured with
a trocar, and the cannula is left in place. Through this, and the can-
nula which has been left in the artery, both vessels are now at the same
time very gently injected, in a direction away from the heart, the artery
with a red and the vein with a blue liquid. The result is that each
injection penetrates to the capillaries, and the part assumes the hue
proper to it in life. The reason why this procedure enables the venous
injection to pass the valves is supposed to be, that the liquid previously
injected has either distended the veins sufficiently to make the valves
incompetent, or has actually forced them against the sides of the ves-
sels. At all events, there is no doubt that the device is successful, but
its practice is said to demand a great deal of skill and patience.
By means of this method of injection the following facts have been
learned in regard to the circulation in the fingers : There is a special
collateral (functional) circulation in the fingers, quite distinct from that
which simply nourishes the tissues. The branches given off by the
collateral arteries are so few and so thin that the trunks reach the last
phalanx but little reduced in size, and terminate in an arch at about
the middle of the palmar aspect of the phalanx. Numerous arterial
" bouquets " are given off from the arch, and divide in the pulp of
the finger. They have no verue comites. The capillaries show a special
disposition in the pulp of the finger which is quite characteristic ; an
arteriole of comparatively large size is seen to divide suddenly into a
" bouquet " of large capillaries (from 0'04 to O08 mm. in diameter).
These capillaries form glomeruli, and then come together again to form
a venule. The glomeruli are found in great abundance at the middle
of the palmar aspect of the last phalanx, under the upper two thirds
of the nail, and at the thenar and hypothenar eminences. At all these
points the ordinary type of nutritive vascularization is found side by
side with this special circulation.
The veins of the fingers arise for the most part from the last pha-
lanx ; their radicles unite almost at once to form trunks of compara-
tively large size, which proceed toward the root of the finger, forming
a subcutaneous layer which almost covers the dorsal aspect. These
veins do not form irregular plexuses, but follow a longitudinal course
to the first phalanx, anastomosing freely.
The chief characteristic of this special circulation lies in the great
caliber of the vessels in proportion to the nutritive demands of the
336
MISCELLANY.
[N. Y. Med. JorR.
first phalanx. M. Boureeret thinks that the object of the arrangement
is to supplement the nutritive circulation and to warm the parts, but
M. Poirier suggests that it may have something to do with the exquisite
sensibility of the localities concerned.
" The Micrococcus Limbergeri," says the " American Practitioner,"
" has recently been the subject of numerous investigations. In fact,
every stranger, soon after his arrival in Germany, attempts to investi-
gate it, and with very various results. Unlike those mentioned above,
it is very difficult to isolate. One plan, lately suggested by Prof. O'D.
Rossa (' United Ireland,' 1885), seems to be feasible. It consists in iso-
lating the micrococcus, together with its pabulum and a large portion
of the adjoining sidewalk, by the judicious application of a few pounds
of dynamite. This species is not good to eat. Your readers will now
be relieved to learn that for the present they will be spared any further
remarks upon bacteriology, as the spiro-gyra barrel-orr/ani is breeding
so freely upon some pieces of Lohengrin, just outside the window, that
all other matters must be suspended till the disease has been isolated
with a boot-jack and destroyed by a moist heat of 212° F."
Even-handed Justice in Paris. — The " Progres medical " announces
that the pharmaceutical interne Reinchard, the involuntary author of
the mistake which lately caused the death of two patients at the hopi-
tal Saiyit-Louis, was arraigned before the correctional tribunal on the
26th of August, charged with homicide by imprudence. He was con-
demned to three months' imprisonment and fined fifty francs. The Sis-
ter who purged one of the patients without authorization, and thus
caused his death, has not yet been prosecuted. " It will be remem-
bered," says our contemporary, •' that things went differently when it
was a question of lay nurses. Singular justice ; singular administra-
tion ! "
The Disposal of Anatomical Material in Paris. — According to the
" Progres medical," the prefect of police has ordered that henceforth
the debris of cadavers from the dissecting-rooms shall be incinerated in
the special apparatus lately established in the cimetiire de VEst, or
buried in some other Paris cemetery.
A Munificent Bequest. — The same journal says that the Countess
of Bose, who died in 1883, bequeathed to the Marburg faculty of Medi-
cine 800,000 marks (about $200,000) for prizes, for defraying the trav-
eling expenses of young physicians, etc.
The Cartwright Lectures. — The " Medical News," of Philadelphia,
learns that the next course is to be given by Dr. Osier, of that city.
Papine. — Concerning this preparation, Dr. H. T. Bruce, of Waverly,
Ala., says : " I have tested papine ; it acts charmingly as an anodyne.
One of the patients could not tolerate morphine, owing to the nausea
and vomiting it occasioned. In this patient pain was allayed and tran-
quil sleep produced, and no evil effects followed. I noticed that its
effects were quicker than was usual from opium. So far I am much
pleased, and deem it an indispensable remedy."
THERAPEUTICAL NOTES.
Nitro-glycerin in the Treatment of Hiccough. — Dr. O. T. Schultz,
of Mount Vernon, Indiana ("American Practitioner,"), relates the case
of a phthisical patient, fifty-eight years old, who had suffered for nine
days with persistent hiccough, which had brought him to a very low-
condition, and had been only slightly ameliorated at times by various
remedies, including galvanization of the phrenic nerves and of the epi-
gastric region, and faradization along the attachment of the diaphragm.
As the patient had formerly suffered from angina pectoris, the author
reasoned that the hiccough might be due to a similar cause. Accord-
ingly, on the tenth day, he gave one drop of a one-per-cent. solution of
nitro-glycerin at 8 o'clock in the morning, and repeated it at 9 o'clock.
A moderate degree of bursting headache set in at once, the hiccough
became easier and less frequent, and by 9.30 o'clock it had ceased alto-
gether. The use of the drug was continued every two hours. At 2
p. m., after the patient had drank a glass of iced milk, the spasms ap-
peared again, but yielded quickly to a fresh dose. During the after-
noon and night there was only an occasional hiccough, but the next day
there were two short attacks in the afternoon. The medicine wag con-
tinued, and an occasional dose was given on the twelfth day, when the
hiccough had entirely ceased.
Ficus Doliaria in the Treatment of Miners' Anaemia. — Bouchut
(" Paris med." ; " Nouveaux remedes ") describes doliarina as a powder
prepared with the juice of the Firm doliaria, a plant indigenous to
Brazil, where the Ankylostoma duodenale (the parasite which causes
miners' anaemia) prevails endemically. The powder contains also aro-
matics and iron. The dose for an adult is a drachm three times a day.
In the case of a patient treated by Biiumler the ingestion of the first
few doses was followed by borborygmi with pains in the upper part of
the abdomen. The next day there were several loose stools, and the
evacuations contained great numbers of the ankylostoma. On account
of the patient's general condition, due to phthisis, the treatment soon
had to be suspended, but it was afterward resumed with success.
Biiumler remarks that doliarina, although slower in its action than
male fern, and doubtless less energetic in dislodging the parasite, in-
volves no danger, while the use of male fern demands great care. The
juice of the Ficus doliaria contains vegetable pepsin, which digests the
worms, so that, like papain, it is a worm-consumer (vermivore).
Sulphide of Carbon as a Revulsive. — "Nouveaux remedes" says:
Take a piece of cotton of the proper size, sprinkle it lightly with sul-
phide of carbon, apply it to the skin, and cover it with oiled silk. In
fifteen seconds the revulsive action will be observed, as shown by brisk
burning. If the application is continued for more than thirty seconds
the pain becomes intolerable.
Hydrofluoric Acid as an Antiseptic. — According to the same jour-
nal, hydrofluoric acid is one of the most powerful antiseptics, and has
been used in tuberculosis, both pulmonary and surgical (wounds and
glandular inflammations in tuberculous subjects). As a surgical anti-
septic it has yielded interesting results. Commercial hydrofluoric acid
should be diluted in the proportion of 1 to 2,000, 1 to 1,000, or 1 to
500. Internally, it may be used by inhalation. The patient is to be
placed in a cabinet in which two drachms and a half of the commercial
acid, diluted with its own weight of water, in a leaden vessel, are evapo-
rated over a water-bath. The inhalation, which should last at least an
hour, is to be repeated every day.
Sulphate of Iron in the Gastric Catarrh of Infants. — When ab-
sorbents and tonics fail to correct the acidity, Roth (" Pest. med.-chir.
Presse " ; " Conseiller med." ; " Rev. des mal. de l'enfance ") resorts to
sulphate of iron, which acts favorably in a variety of ways. In the
first place, it is a disinfectant ; under its use, the evacuations are
changed in color and lose their offensive odor. Being an astringent,
it contracts the turgid mucous membrane and coagulates albuminous
matters. In order that these effects may be decided, its use should be
continued for several days. The author employs the following formula ;
Sulphate of iron \\ grain ;
Mucilage of acacia, > ^ g drachmg
Syrup, )
A teaspoonful to be given every two hours.
Mercury in the Abortive Treatment of Typhoid Fever. — Accord-
ing to Kalb ("Berk klin. Woch." ; " Gaz. hebd. de med. et de chir."),
mercurial frictions, practiced before the ninth day, produce complete
defervescence in a few days. The inner aspect of the thigh is to be
chosen, and the frictions should last half an hour. At the same time
Kalb gives large quantities of alcohol to counteract the damage to nu-
trition.
Injections for Foetid Leucorrhcea. — A contributor to the "Union
medicale " gives the following formulae :
Chlorate of potassium 12 parts;
Wine of opium 10 "
Tar-water 300 "
Add three tablespoonfuls to half a pint of warm water.
Salicylate of sodium 20 parts :
Salicylic acid 1 part ;
Tincture of eucalyptus 45 parts ;
Wine, or white vinegar 300 "
Add two tablespoonfuls to half a pint of warm water.
THE NEW YORK MEDICAL JOURNAL, September 26, 1885.
W t ft u r e s a n b '^fcbrfssss.
A CLINICAL LECTURE ON
DISEASE OF THE HEART AND LUNGS,
WITH SPECIAL REFERENCE TO
PHYSICAL DIAGNOSIS.
By STEPHEN S. BURT, M. D.,
PROFESSOR OF PHYSICAL DIAGNOSIS IN THE NEW YORK POST-GRADUATE
MEDICAL SCHOOL AND HOSPITAL.
\Yhili5 directing our attention more especially to the
physical diagnosis of disease of the heart and lungs, we are
constantly reminded of the intimate relations that exist be-
tween them and the remaining organs of the body. A
study of these relations forces upon us the conviction that
only by thorough knowledge of disease in general may we
hope to arrive at anything like precision in the diagnosis
of special subjects.
He is indeed a poor practitioner who allows himself to
be so carried away by some absorbing specialty as to lose
his interest in the general health of the body. But what
shall we say, on the other hand, of the physician who be-
lieves physical exploration unnecessary, and goes his way,
having prescribed for symptoms only?
To the general practitioner an understanding of the
methods of physical diagnosis has now become a necessity,
and one that is well recognized. It is expected by his pa-
tient and demanded by the profession, so universally, in-
deed, that some are forced to go through a sort of mum-
mery for its moral effect upon the patient, when in reality
there is little if any true perception of what the examina-
tion reveals. Fortunately, however, this class is in the
minority. There is a desire prevalent in the profession, as
shown by the increasing numbers at our clinical schools, to
grasp the subject of physical diagnosis, and ere long no
doctor will tliink of prescribing for a cough until he has
discovered the cause thereof. No practitioner will mistake
a functional for an organic disease of the heart ; nor will he
make life miserable to a patient just because an organic
murmur has been found. He will be capable of explaining
that life may continue in comparative comfort so long as
compensatory hypertrophy lasts. Furthermore, he will be
able not only to recognize failing compensation, but also to
ward off its fatal effects, perhaps for years, by judicious
treatment, and finally he will be less likely to interfere
when nature does not call for aid — an achievement perhaps
one of the greatest in medicine.
Now, let us turn to the study of diseases of the chest as
they are presented, not in books, but at the clinic. It is
one thing to learn the symptoms and physical signs of dis-
ease, and quite another to recognize them in the patient.
Here lies the difference in medical men. Book knowledge
is important, but some never get beyond it.
The first patient that it is our privilege to examine gives
a good family history. She is thirty years of age, has not
had rheumatism, nor any severe illness. She complains
chiefly of loss of appetite, headache, and flatulence. Upon
exertion and on exposure to cold she has a slight cough.
You observe that it is not until the leading question has
been asked that she tells of any shortness of breath on ex-
ertion. Her symptoms are mainly those of dyspepsia. But
those disorders of the digestive tract that receive the name
of dyspepsia are not always so innocent as they might
seem. Not infrequently a grave kidney lesion may be
found lurking in the background, and then again the
heart may be at fault. A careful examination has excluded
the probability of a kidney complication in this case. We
will now investigate the heart. Upon inspection, it is seen
that the apical impulse is somewhat to the left and below
its normal position. The impulse, on palpation, is found to
be slightly increased in force. Percussion does not give a
marked increase in the cardiac area. Auscultation, how-
ever, reveals a soft, blowing systolic murmur, extending to
the left, with the point of maximum intensity in the mitral
area. Mitral insufficiency is the lesion, and for this the
heart muscles fairly compensate. There is neither oedema
nor cyanosis.
This is a very instructive case, illustrating as it does
one of the secondary symptoms of heart disease — namely,
flatulent dyspepsia. Long before serious engorgement be-
comes apparent there is this slight alteration in the circula-
tion which results in defective digestion. And, too, a little
unusual exertion or some slight exposure of the neck and
shoulders produces a dry cough. Besides, if you closely
watch these patients you will see that there is dyspnoea, not
upon ordinary exertion, so long as it is confined to a plain
surface, but during an ascent of a very slight elevation, or
on any unusual exercise. As a result also of this, the
bright-red color of the lips is seen to change to a much
darker hue. I have had just such an instance under ob-
servation for the past four years. The patient was treated
for simple dyspepsia, with very indifferent results, her heart
lesion being' unrecognized. But when the real cause of her
trouble became known she made rapid improvement. A
pill containing a grain each of digitalis, iron, and quinine,
in addition to the stomach mixture, with, now and then,
medicine for the intestines, comprised most of the treat-
ment. The slight cough, which is provoked by a similar
condition in the pulmonary circulation, is prevented by tak-
ing only moderate exercise and by keeping the superficial
circulation active with sufficient clothing.
There is still another very interesting example of ve-
nous congestion resulting from heart disease that occurs to
me. A patient who was completely prostrated each month
by menorrhagia came for treatment, but her errand was as
fruitless as it had been elsewhere until I discovered that she
had a stenosis of the mitral orifice. No lesion could bo
found as a local cause. Concluding, therefore, that the
excessive haemorrhage was due to venous stasis, I put her
upon large doses of the infusion of digitalis during that
period, and the treatment proved most efficacious.
On the other hand, it is a matter of frequent remark, the
number of patients that come firmly convinced they are suf-
fering from an organic disease of the heart, because of the
pain and palpitation that often attends dyspepsia. A physi-
338
BURT: LECTURE ON DISEASE OF THE HEART AND L UN OS. [N. Y. Med. Joan.,
cal examination enables the physician to dispel all these
fears, while properly directed remedies will remove the
cause, quiet the heart, and quell the pain.
Here we have exemplified the interdependence of vis-
cera, and, at the same time, the importance of not attending
to one to the neglect of another part of the body.
We now have a patient on whom the ravages of time
and disease have set their stamp. It is seen, by pitting on
pressure, that his ankles are both oedematous. His face,
marked with fine red streaks, is pale, and his lips are slight-
ly cyanotic. The pulse is irregular and small. He tells us
that exertion produces shortness of breath, and that upon
two occasions he has had haemoptysis. Thus we have evi-
dence of an increased venous and a diminished arterial
pressure. By palpation we find the apex of the heart a
little to the left of its normal position, with its impulse
fairly strong, while epigastric pulsation is forcible. Upon
auscultation there is accentuation of the pulmonary second
sound, and just over the apex can be heard a systolic mur-
mur. This murmur is not heard in the back ; neither is it
carried to the left nor to the right. It is the indication of
mitral regurgitation, but there is probably very little regur-
gitation as compared with the amount of obstruction at
this orifice.
Delafield says: "The same lesion frequently produces
both stenosis and insufficiency of a valve." And here we
have the physical signs that most commonly proclaim this
condition.
Such a murmur is much oftener present than the auricu-
lar systolic, or so-called mitral presystolic, murmur with
this lesion. A feeble mitral systolic murmur, due to a
weak ventricle, is also confined to the area of the apex, but
that is not the case in hand. Exceptionally, a systolic mur-
mur of the kind we have here gives place temporarily to a
presystolic murmur. Obstruction of the mitral orifice pro-
duces an accentuation of the pulmonary second sound.
This is brought about in two ways — first, by pulmonary
engorgement and consequent hypertrophy of the right ven-
tricle, and, second, by the diminution of the aortic second
sound from decreased arterial pressure in the general circu-
lation.
When hypertrophy of the left auricle is sufficiently in
excess of dilatation to follow up the at first passive flow of
blood by a firm contraction, in the completion of auricular
systole, we may observe the so-called mitral presystolic mur-
mur. But under other conditions of stenosis, unless the
valve is closed during ventricular systole, such a systolic
murmur will be produced as we find here. The case is of
further interest in that we are able to restore the arterial
circulation, sufficiently at least to do away with the dropsy.
In order to accomplish this we must increase the quality of
his blood by food, rest, and tonic medicines. By the addi-
tion of digitalis, compensation will be re-established, and
thus nature assisted by a timely and not unintelligent inter-
ference.
The history and symptoms of patient number three are
of a cough, attended at one time by white frothy sputa, at
another by muco-purulent expectoration. This began with an
haemoptysis early in the spring. She has night sweats, and
believes she is losing flesh and strength. A brother and a
sister died of consumption. We are led naturally to sus-
pect incipient phthisis ; but the diagnosis of the early part
of the first stage, by physical signs, is not always an easy
matter ; and it is quite beyond the reach of one who has not
given some special attention to the subject. We know that
fremitus is more marked at the right apex in health than
at the left, that the pitch is higher on percussion, that ex-
piration is higher in pitch and longer in duration upon aus-
cultation, and also that vocal resonance is exaggerated.
With these signs at the left apex we should be almost cer
tain of phthisis. How, then, are we to determine whether
there is phthisis upon the right side ? In the first place
the disparity seems to be greater than is found ordinarily
in health ; and. secondly, there is evidence of a circum-
scribed bronchitis, shown by the localized subcrepitant
rales. Besides, there are a few crackling and crepitant
rales, indicating some slight co-existing pleurisy and pneu-
monia.
These adventitious signs are confirmatory evidence, and,
taken in connection with an elevation of temperature, com-
plete the diagnosis.
The advantage of detecting the presence of phthisis at
an early stage is very great, for that is the time in which
judicious treatment is productive of the best results. While,
unfortunately, the greater number do not, still it is a well-
established fact that patients do recover from phthisis.
We find this demonstrated in autopsies, when death has
taken place from other causes, by the presence of cicatrices
or encapsulated cretaceous remains of old phthisis. It is
also within the experience of many of us to have watched
the progress toward recovery. Localized pneumonia under-
goes resolution, circumscribed bronchitis disappears, and
with thein all decisive evidence of pulmonary phthisis.
The next patient comes with a history of a cough which
has lasted nearly two years, associated with night sweats,
loss of flesh and strength, but no haemoptysis. His father
and a brother died of what he thinks was consumption.
Upon inspection, we see that he is much emaciated, espe-
cially about the chest. Under both clavicles there is de-
pression, the retraction being more marked upon the right
side. On palpation, we find fremitus exaggerated upon the
right side, and his respirations are twenty-four a minute.
Light percussion shows dullness in the upper part of
the right infra-clavicular region and over the upper half
of the left side of the chest, while forcible percussion brings
out cracked-pot resonance from the left infra-clavicular re-
gion. Auscultation reveals bronchial breathing and bron-
chophony over the right, with amphoric respiration and
whispering pectoriloquy in front upon the left side, while
behind on the left side are large and small bubbling rales.
Thus we have an example of the beginning of pulmonary
phthisis at the same time with one approaching its end. It
is but ill-conceived advice that sends a patient with lungs
in this advanced stage of destruction from home and
friends, to find discomfort and finally death among strangers
in a strange land ; and it would seem that a knowledge of
the physical signs of disease should enable physicians to
avoid doing this thing.
Sept. 26, 1885.]
BAUDUY: COCAINE IN MELANCHOLIA.
339
There are a few cases, to be sure, where phthisis ad-
vances to the. stage of excavation and remains station-
ary, the patient practically recovering, but this is rather
exceptional. If the physician can decide that the phthisis
is non-progressive, and finds the pulse good and the
general condition of his patient fair, he may give a guarded
favorable prognosis, and possibly allow him to try a change
of scene and climate.
To return, then, to our opening proposition, we see in
all these cases that a comprehensive knowledge of disease is
quite indispensable to a specific understanding of the mala-
dy under which each patient labors. And without physical
exploration there is no certainty, for different diseases have
so many symptoms in common that dependence upon symp-
toms alone is often misleading. By a thorough examination
of each case the physician exhausts all possible causes of
any given complaint. He begins to know definitely the
matter in hand. He knows what is not as well as what is
before him. He can direct his remedies to the true seat of
the disorder, and he is not under the necessity of trying
what may prove an ill-judged experiment, while without
this examination his diagnosis is more or less guess-work.
He may be right, for a guess has always one chance of
being right; but he will often be wrong, and wrong, too,
from avoidable causes.
I can not, therefore, urge upon the student too forcibly
the importance of a thorough familiarity with physical
diagnosis. He will not fail to be convinced of its supreme
value in all cases of thoracic disease.
GBrightal Communications.
PHYSIOLOGICAL, PATHOLOGICAL, AND CLINICAL
NOTES ON
HYDROCHLORATE OF COCAINE,
WITH SPECIAL REFERENCE TO ITS USE IN MELANCHOLIA.
A PRELIMINARY STUDY*
By JEROME K. BATJDUY, M. D., LL. D.,
PROFESSOR OF PSYCHOLOGICAL MEDICINE AND DISEASES OF THE NERVOUS
SYSTEM, MISSOURI MEDICAL COLLEGE ; SENIOR ATTENDING PHYSICIAN TO
ST. VINCENT'S INSTITUTION FOR THE INSANE, ST. LOUIS.
This remedy is one of the great discoveries of the
present century. Notwithstanding its recent triumphs in
ophthalmological fields, I believe it will have its greatest
future in the treatment of many forms of obstinate nervous
disease. Ansemia, depression, prostration, neurasthenia,
and particularly many disturbances of the vaso-motor sys-
tem, will be the domain of its most brilliant therapeutical
achievements. Having experimented extensively and per-
severingly with this wonderful drug, I feel it incumbent
upon me to lay before the profession the conclusions I have
reached, although many of them are still not sufficiently
matured by time and experience.
My attention to the internal use of the drug was first
* Read before the American Neurological Association, June 17,
1885.
awakened early in January of the present year by reading
an able article by a German physician, Dr. Fleischl, of
Vienna, detailing the results he had obtained in the treat-
ment of alcoholism and morphinism, in which he enthusi-
astically maintained that inebriate asylums were a thing of
the past.
I shall consider the drug in relation to its effects on all
the more important organs.
The Stomach. — After the exhibition of a dose of co-
caine to one unaccustomed to it, intense and persistent nau-
sea generally manifests itself. So certainly is this a fact
that it is necessary to administer it several hours before a
meal is taken ; otherwise the anorexia which follows, along
with the nausea, will prevent the taking of nourishment.
This fact is to be especially remembered in the treatment
of melancholia, in which (so far as can be learned) I was
the first to suggest its use. If this is not remembered, it
will, of course, greatly militate against the result to be
attained, since systematic feeding holds an important place
in the treatment of this condition.
One of the most striking and, at the same time, inter-
esting effects of cocaine upon this organ, from a therapeutic
standpoint, is that vomiting is not possible, however intense
the nausea may be. This is due either to a paralysis of the
gastric motor-nerve supply, which seems to be almost sui
generis, or to a selective anaesthetic effect. Although the
appetite is abolished, there is no interference with the diges-
tion of food taken, in spite of the anorexia. The following
incident led to this discovery :
A patient, to whom cocaine was administered some hours
after the ingestion of an excessively large meal, was suddenly
seized with violent symptoms of indigestion. As he was in
great distress, an ordinary domestic emetic was given ; this fail-
ing to act, one or two more strong doses of a similar character
were administered with no result — such as large doses of salt,
mustard, and warm water. They were given until the stomach
was distended, with no effect exoept to add to the patient's dis-
tress. Ipecacuanha and alum, in fair doses, likewise proved
futile. Everything having failed, and thy patient's distress from
the emetic agents becoming very great, efforts in this direc-
tion were stopped. In due course of time the contents of the
stomach were carried off by a profuse diarrhcea, which afforded
the first relief the patient experienced.
From this and analogous cases I concluded that cocaine
should be ranked among the most efficient of anti-emetic
remedies. For this I also claim priority, for, early in Janu-
ary, 1885, I suggested to my friend, the late Dr. P, V.
Schenck, to make trial of it in cases of the obstinate vomit-
ing of pregnancy. He soon reported before the Medico-
Chirurgical Society of St. Louis most complete and brilliant
success in two cases in which all ordinary remedies had
failed. He was enthusiastic on the subject, and warmly
urged me to publish my results. His early death, unfortu-
nately, prevented further experiments in this direction, as I
myself have not treated cases of this character for many
years.
I have already referred to the loss of appetite which the
drug produces. The anorexia is the most certain and com-
plete I have ever witnessed as resulting from the use of any
drug.
340 BAVDOY: COCAINE
In cases of the ordinarily uncontrollable vomiting of
hysteria, as well as in all cases in which it is desirable to
administer nauseating drugs to patients presenting gastric
irritability — ipecacuanha in dysentery, for example — I am
convinced that cocaine will prove very useful.
Genito-urinary System. — Although I have made no
chemical or microscopical investigation of the urine as
modified by the use of cocaine, the time at my disposal
having been too limited, I believe that the urinary organs
offer an extensive field for observation. It is certain that it
produces a largely increased flow of urine, and, as a result
of its abuse, a slightly paralytic condition of the bladder.
The patient finds it difficult to begin the act of micturition,
and, when the act should have been finished, the urine con-
tinues to dribble away for some time, as in the incontinence
observed after overdistension from retention. From this
fact it has occurred to me that it would be well to try the
remedy in cases of irritable bladder, whether due to cystitis
or to perverted nervous and muscular action, a condition
which so frequently baffles the best efforts of the physician.
Upon the sexual organs cocaine acts as a direct stimu-
lant. Among aphrodisiacs I have found it the only reliable
agent. In this as well as in other regards it proves directly
antagonistic to morphine, which, as is well known, is a pow-
erful anaphrodisiac. The most remarkable results may be
effected by bringing the system under the conjoined influ-
ence of the two drugs. Veritably atrocious teasing effects
are thus induced ; the individual will be swayed by the
stimulation of his desires to violent and frequently repeated
sexual efforts which will almost invariably prove futile or
be held in abeyance by the restraining influence of the
morphine. The tortures of Tantalus will be repeated, the
punishment being transferred to the sexual appetite, which
can not be gratified, and being, if anything, more acute
than that caused by excitations of thirst and hunger.
A singular effect of the drug is sometimes to be ob-
served in the act of coition. There seems to be present a
state of erethism, making it difficult for the individual to
determine precisely when the orgasm has been begun or
completed. This singular state of affairs is, in some in-
stances, so pronounced as to perplex the individual as to
the time when withdrawal should be accomplished. The
condition is probably due to a morbid irritability resulting
in a disturbance of the reflexes.
Circulatory System and Respiration. — The heart's
action is increased both in strength and in frequency under
the influence of medicinal doses of cocaine. This is con-
firmatory of the effects observed by South American travel-
ers from chewing the leaves of the plant. When the dose
is excessive, or its use too long continued, the pulse be-
comes weak and still more frequent, and dyspnoea follows
slight muscular effort. The respirations are always in-
creased in frequency to correspond with the acceleration of
the heart's action.
The Vaso-motor Nervous System. — It is probable
that many of the phenomena already described are due to
the effect of the drug upon the nervous apparatus of the
arterioles and capillaries, but I desire to lay some stress
upon certain effects of this character not alluded to before.
IN MELANCHOLIA. [N. Y. Med. J<>( k.,
Immediately after the hypodermic injection of a full dose
of cocaine the capillaries of the skin become contracted.
If there has been any flushed condition of the face, it is
immediately replaced by very pronounced pallor. The
mouth and throat become dry — at least subjectively — the
pupils dilate, and profuse diaphoresis usually occurs, if the
dose is large and repeated.
In these results there is a strong resemblance to the
action of pilocarpine, and at the same time a very remarka-
ble dissimilarity, all therapeutically in favor of cocaine. ■
Jaborandi and its alkaloid produce nausea, but also vom-
iting ; they cause diaphoresis, but at the same time saliva-
tion ; they depress the action of the heart, sometimes to
an alarming degree, the reverse of the ordinary effects of
cocaine. Not quite so certain nor so persistent in its effects
upon the secretions of the skin as pilocarpine, it is far more
agreeable and safe in its action in case9 of cardiac dropsy.
The Cerebro-spinal Nervous System. — The reflexes
are all exaggerated. This is peculiarly shown in the act of
defecation. It should be observed that, in consequence of
the increased secretion of the skin and kidneys, the alvine
evacuations become dry, hard, and infrequent. When there
is an attempt made to relieve the bowels, the act is accom-
panied by spasmodic contractions of the abdominal muscles,
efforts simulating the throes of the parturient female ; the
hardened faeces are expelled with force, and every muscle
in the body seems to partake of the spasmodic action.
There is thus danger of laceration of the sphincter ani, for-
mation of fissure of the anus, aggravation of haemorrhoids,
and, in persons of advanced age whose arteries are degener-
ated, cerebral haemorrhage, as a consequence of these vio-
lent expulsive efforts.
As soon as a medicinal dose of cocaine has reached the
general circulation, a feeling of well-being is experienced ;
all sense of physical or mental fatigue which may have
been present disappears as if by magic ; the mind becomes
excessively clear ; ideas constantly flow, and the faculty of
speech seems especially exalted. In fact, it would thus
appear that the island of Reil and adjacent speech centers
felt especially the force of the drug. So long as these
effects are continued, sleep is impossible ; no fatigue is ex-
perienced from continued muscular movements, no matter
how prolonged.
These effects upon the cerebrum give the key to its em-
ployment as a therapeutic agent.
Therapeutic Effects. — It has been well known for
some time that the fluid extract of coca was a valuable
remedy in the treatment of alcoholism and the opium habit,
but it is not to be compared with the alkaloid cocaine in
this regard. For a remedy of uncertain strength and action
we have in cocaine one whose effects can be predicted with
mathematical certainty. It not only replaces alcohol and
morphine, but it generates a positive disgust for these agents.
They can be withdrawn completely and at once without the
slightest suffering or injury, and the cocaine itself may be
gradually dispensed with, thus eventuating in perfect re-
covery.
The only caution to be observed in these cases is to ad
minister the drag hypodermically, and this by the hand of
Sept. 26, 1885.]
the physician himself. This I particularly insist upon. The
drag should not be known to the patient, nor the amount
of the alkaloid which is being given. If these precautions
are not adopted there is great danger — nay, a certainty —
that a cocaine habit will be formed, more disastrous in its
results than alcoholism or morphinism.
I have already referred to its uses in the obstinate vom-
iting of pregnancy and of hysteria, and would only add in this
relation that there is nothing which relieves any of the ordi-
nary manifestations of hysteria so rapidly and completely as
a hypodermic injection of cocaine. The same effects may
be expected from its use in cerebral and spinal anaemia,
"spinal irritation," neurasthenia, and, in general, in all
those cases where the brain and spinal cord do not properly
perform their functions from want of proper blood-supply ;
in all these I believe cocaine will prove the remedy par ex-
cellence.
I have tested its powers in the cold stage of intermittent
fever, and have secured the happiest results. There is a
return at once of a feeling of warmth, and the skin begins
to act, thus bridging over both the cold and the hot stage
of the fever. In pernicious cases I have no doubt it would
prove of the greatest value. Indeed, as the temperature is
increased, both subjectively and objectively, at least 1° F., I
have great expectations of its value in the algid stage of
even such a disease as cholera.
In chorea gravior, in convalescence from protracted ill-
ness of any kind, in blood-poisoning — in fine, in all cases
where there is excessive tissue metamorphosis without cor-
responding constructive changes — I believe cocaine to be a
most valuable remedy.
Insanity, however, I believe furnishes the great thera-
peutic field for the useful administration of cocaine. Espe-
cially is this true of melancholia and hysterical and hypo-
chondriacal insanity ; in these especially there is a great
future before it.
The records of all asylums will show that melancholia is
usually a long-continued and tedious disease to treat — one
which most alienists naturally dread to encounter. The
rapid relief and satisfactory therapeutical results which are
observed in mania so frequently, the shortening of its dura-
tion, and the control of its more prominent manifestations,
are not observed in the treatment of melancholia. Pro-
tracted mental depression with accompanying physical pros-
tration are the constant conditions present. Anything
which will alleviate this condition and shorten its duration
is a boon to suffering humanity. I therefore urge upon the
profession to fairly, extensively, and perseveringly test this
drug and verify or disprove the wonderful results I pro-
fess to have secured in this direction. These effects are so
wonderful that they must be witnessed in order to be be-
lieved.
As yet I have not had so much time as is desirable to
fully experiment with this remedy, but my results obtained
at St. Vincent's Institution during the past six weeks have
been in every case eminently satisfactory. In certain cases,
only to be ascertained by experiment with the drug, it cer-
tainly appears to act as a specific. In most cases of mel-
ancholia, even those of very long standing, its effects are
341
manifested almost instantly after giving it hypodermically.
My usual method has been to inject one grain, dissolved in
ten minims of distilled water. Making all allowance for
idiosyncrasies, differences in individuals, variations in the
purity of the drug, and other factors not necessary to men-
tion, it may be said that within five minutes the specific
effects are fully manifested. The patient who has been
morose, silent, taciturn, a prey to the most profound grief
or sadness, recovers his normal self, begins to talk about
his case, and wonders how he could ever have experienced
such gloomy ideas. The cloud over the mind is dispelled,
and, instead of the anorexia felt by the normal individual
who takes the same dose experimentally, the melancholiac
no longer refuses food, and, in place of inveterate insom-
nia, will have a good night's rest. It is in recent cases
that its curative effects are most manifest. In those of
prolonged standing these results are apt to be rather tran-
sitory. In one case, that of a suicidal melancholiac from
Arkansas, recently admitted into St. Vincent's Asylum with
an ugly gash in his throat, the duration of the disease was
less than a month from the time of his arrival at the insti-
tution. Only five injections of cocaine were given, and he
was discharged, completely restored to mental health, before
his injury about the throat had completely cicatrized.
About fifteen patients are yet under treatment, some of
whom are greatly improved, some almost convalescent,
while a few have received very little permanent benefit
from its administration.
A very intelligent young man (still my patient) has
written a graphic description of the effects of the cocaine
treatment upon his melancholia, for which he alleges the
best results, even declaring that it has induced an abolition
of his suicidal tendencies. This letter I shall be happy to
read to any of the gentlemen present who so desire. In
chronic cases the effects are to produce a "lucid interval"
which may continue from one to twenty hours. It is too
much to expect that permanent good results can be effected
in such cases from any course of treatment whatsoever.
Toxic Effects. — Too frequently repeated medicinal
doses or very large quantities of the drug, injected subcu-
taneously at once, produce results alarming both to the sub-
ject and to the spectators. The entire surface becomes pale
and covered with perspiration ; the pupils dilate gradually
and are insensible to light ; profound nausea, but no vomit-
ing, follows ; the muscles of mastication become more or less
rigid and affected with clonic contractions, this effect being
produced only among the earlier physiological and toxic
effects ; there are violent grating and gnashing of the teeth,
so that small portions of the enamel are ground off. Tonic
contractions of the same muscles (trismus) are sometimes
observed, but exceptionally. The eyes assume a fixed, wild,
staring gaze that is as characteristic as it is indescribable.
There is ceaseless jactitation, with a sensation of wild nerv-
ousness that is almost unbearable. There is voluminous lo-
quacity, an extraordinary fluency of speech, the volubility
of which must be witnessed to be credited. Excitations of
the sexual propensities, one rapidly succeeding the other
with astonishing celerity, of a teasing character, are gener-
ally observed. Superadd to these phenomena visual and
BAUDUY: COCAINE IN MELANCHOLIA.
342
BAUDUY: COCAINE IN MELANCHOLIA.
[N. Y. Med. Jour.,
auditory hallucinations and illusions of the most painful
character, and you have a conception of the clinical charac-
teristics of acute cocainism. I do not know the lethal dose
of cocaine. If given in sufficient quantity, it would doubt-
less induce epileptiform convulsions, terminating in death
from exhaustion.
Chronic cocainism, or the cocaine habit, presents in an
exaggerated form most of the phenomena just described,
and some additional ones worthy of record. One case has
come under my observation which I will give in extenso :
In February last a retired druggist was committed to my
charge. He had for many years been a hopeless victim to the
morphine habit. The morphine was suddenly withdrawn and
hypodermic injections of from a grain to a grain and a half of co-
caine, twice daily, were substituted. The result was brilliant and
marvelously rapid. The craving for morphine immediately ceased,
and all the distressing phenomena usually following the sudden
cessation of the use of the drug failed to manifest themselves.
Cocaine answered every purpose as a nervous stimulant. But
I was somewhat alarmed at ascertaining that a corresponding
demand for cocaine was rapidly developing itself — that a cocaine
Jiabit, the literature of which is as yet a blank, was being
formed. Alarmed and dreading the responsibility of subjecting
him to unknown and, probably, pernicious influences, I sought
immediately to diminish the doses he was taking. Against this,
however, he rebelled, and my protests and arguments failed to
withdraw him from the rapid formation of a habit apparently
more alarming in its results than the terrible slavery entailed
upon him by his former habit. My consent to the further ad-
ministration of cocaine was therefore withdrawn. At that time
all craving for morphine and all necessity for its use had disap-
peared.
Owing to his former occupation, he had no difficulty in pro-
curing the drug in large quantities and taking it by the subcu-
taneous method. His familiarity with drugs made him all the
more reckless, and he daily became more and more enthralled.
He often took from twenty to thirty grains daily. He has fre-
quently endeavored to shake off the habit, but he finds this
impossible. It is vastly more powerful and fascinating than his
previous tyrannical master. I have frequently prescribed the
free and narcotic use of morphine as an antidote, but this he has
refused to use, seeming to entertain a veritable disgust for the
agent which had formerly exercised such a power over all his
life and actions.
About this time he sustained a severe concussion of the
spine, and came under my daily observation, so that I have had
ample opportunities for observing and studying the effects of
the constant use of this powerful alkaloid in full doses.
The teeth also are implicated in the ravages of this
drug, decay and absorption of the roots occurring.
The effects of its internal use upon the eyes have not,
so far I know, been thoroughly studied, but I am convinced
that the sight becomes enfeebled — a tendency to amblyopia
— which is more intensified in the later stages of chronic
cocainism. I have also observed diminution of the sense
of hearing. Visual hallucinations and illusions, depending
upon cerebral disturbances, and, of course, not upon oph-
thalmic factors, will be referred to subsequently.
The appetite is completely abolished, and, while there is
a subjective sensation of dryness of the mouth and fauces,
the}' arc found moist on inspection. For weeks — nay, for
months —during the continuous administration of the drug
and impregnation of the system by it, all desire for food
ceases, and I am satisfied that inanition would ensue were
not the will-power exercised or forced feeding accomplished.
Although very little nourishment is taken, the body does
not emaciate to any such extent as under ordinary circum-
stances of deprivation. There must be some nervous im-
pression or stimulation produced which greatly compen-
sates for the want of physiological nutrition. This is
probably due to a lessening of tissue metamorphosis to a
minimum.
As regards sleep, the effects are as extraordinary as they
are certain. Insomnia is the rule — an insomnia which is
not followed, commonly speaking, by the exhaustion ordi-
narily thus produced. It is astonishing how night after
night, during which sleep is almost entirely unknown, are
succeeded by days during which the subject is not apparently
greatly depressed, not unrefreshed, during which he is able
— not, however, without effort and procrastination that are
characteristic, increasing — to resume his daily labors, and
even perform brain-work of considerable complexity. In
fact, I have seen this insomnia kept up for three and four
consecutive days and nights, and yet no very marked in-
jury could be observed as a consequence. The nights are
sleepless, yet so great is the fascination of the drug that the
patient prefers his insomnia to his accustomed rest, although
aware that the most arduous duties await him in the morn-
ing. This, to my mind, is an all-conclusive proof of the
dangerous power and terrible slavery to which this alkaloid
subjects its hapless victims.
Nausea and excitations of the sexual functions, already
alluded to, add to the patient's distress ; but these he bears,
overpowered by a fascination which can not be resisted.
He experiences the paradoxical delights of " enjoyable suf-
fering."
Visual and auditory hallucinations and illusions of a
very painful character make him fear that at every pass he
will encounter some dread object. These cocaine effects
will make cowards of the bravest men, causing them to arm
themselves heavily to guard against the ever-anticipated
dread encounter. When the dark vistas and oppressive
silence of night arrive he excludes the pure air of heaven,
however overheated the room may be, and he blocks up the
very key-holes of his doors to exclude unknown and unreal
dangers.
In concluding a study of the phenomena produced by
the poisonous effects of this drug, I may say that the most
alarming are : the most debasing enslavement of the will, a
general demoralization which is as diabolical as it is inde-
scribable, and which tends rapidly toward depravity and to
the development of everything that is degrading and ig-
noble in human nature. The influence of alcohol and of
other alkaloids and narcotics, so well known and so fre-
quently described, pale into insignificance when compared
with that of cocaine. Habits of the most detestable char-
acter ; a settled indifference to every interest of life ; de-
struction of the most noble affections and affiliations ; the
utter death of friendship and of all the nobler qualities;
complete disregard of all social and domestic duties, of
even pressing family necessities and the common interests
Sept. 26, 1885.J
EALLECK: COCAINE
IN MINOR SURGERY.
343
of daily life ; the radical extinction of every previous re-
ligious spark that lias enlivened the soul ; the development
of the most intense selfishness — these are the certain results
of indulgence in this the most powerful and devilish drug
which it has ever been the misfortune of man to abuse.
The most powerful morphine habit of which we can con-
ceive is to the power and bondage of cocaine as the weak-
est sapling to the full-grown oak.
2^ote. — A case has just been reported to me by Dr. A. B. Nichols,
of this city, in which he used one quarter of a grain of hydrochlorate
cocaine internally for vomiting in a woman advanced seven months in
pregnancy. The vomiting was arrested by the first dose administered.
ON THE USE OF COCAINE IN
MINOR SURGERY *
By HENRY TUTIIILL HALLECK, M. D.,
BROOKLYN.
Considerable has been written and said during the last
few months, in the journals and elsewhere, relating to the
use of this new drug. Its use in medicine is of recent ori-
gin, as it has only been known to the profession since Oc-
tober last.
As time passes, however, this drug seems to be gaining
a firmer foothold in therapeutics, and its field of usefulness
is constantly widening the better it becomes known. Almost
every day we hear of some new application to which this
new remedy has been put, and in which it has been found
decidedly useful.
The only drawback to a more extensive use of the reme-
dy is the very high price at which it is sold ; weight for
weight, it is considerably more expensive than 18-carat
gold.f
Since its discovery, or rather its application to medicine,
in October last, it has been used by a large number of phy-
sicians in one or more cases both in surgical and in medical
practice.
I have used the drug in two cases in minor surgical
operations. The most important evidence in its favor, how-
ever, is based upon notes obtained from the surgical practice
of Dr. George Wackerhagen, of this city.
Case I. — This was that of an adult forty-five years of age,
and a case of phimosis. The operation was done under some-
what peculiar circumstances, as it was not in reality a necessary
one. The patient had recently had his two sons operated upon,
and partly for that reason and partly because he was a man of
some scientific acquirements and was anxious to test the effi-
cacy of cocaine, he was desirous of having the operation per-
formed— so much so that he told the doctor if he would not
perform it he would get some one who would. Under these
circumstances Dr. Wackerhagen consented. As the patient
was determined to be a martyr to science, the doctor would
not deter him. A four-per-cent. solution of the hydrochlo-
rate of cocaine was introduced hypodermically at the dorsal
base of the penis, on either side, simultaneously painting the
prepuce thoroughly, two or three times, over the point where
the incision was to be made, after which he waited for fifteen
* Read before the Brooklyn Pathological Society, March 12, 1885.
f Since this was written the price has declined, so that Squibb sells
it at 18 cents a grain.
minutes to get the desired effect. At the expiration of this pe-
riod there was still some tenderness of the foreskin, when the
forceps was applied for the purpose of extension. Five minims
more were introduced hypodermically. Soon the penis became
numb, cold, and blue. Five minutes later the doctor com-
menced the operation, using a clamp after the usual custom in
operating for phimosis. This patient did not have the slightest
pain at any time during the operation, according to his own
statements. He said, further, that he would not have known
that the operation was being performed if he had not been
looking at it.
Case II. — Another adult, twenty-eight years of age. This
was a case of stricture of the urethra. Dr. Wackerhagen com-
menced the operation by introducing 30 minims of the hydro-
chlorate of cocaine with a urethral syringe, afterward closing the
meatus and holding it so as to prevent any escape. Then he in-
jected 10 minims into the tissues at the dorsal base of the penis.
After waiting a sufficient length of timef or the anaesthetic to
take effect, he introduced the urethrotome and cut up to No.
37, French measure, the patient having no pain. He then intro-
duced a bougie, and found the stricture had not been fully
divided. The urethrotome was reintroduced and the stricture
cut to 40, watching carefully at the same time for any symptom
of pain that should manifest itself. At this cutting the patient
did complain of some paiu, but said it was very slight. So little
pain did he experience, according to his own statement, that he
would not think of taking ether were the operation to be per-
formed again.
Case III. — This was another case of urethral stricture in the
male adult. It was very similar to the last, but here no hypo-
dermic of cocaine was used. Thirty minims (ten minims three
times, ten minutes apart) of a four-per-cent. solution of hydro-
chlorate of cocaine were introduced into the urethra and re-
tained for a sufficient length of time to produce anaesthesia,
after which the urethrotome was introduced and the canal cut
to No. 40 in the French scale. The urethra was cut from three
inches and a half back of the meatus to the corona. This man
manifested no symptoms of pain during the operation.
Another marked feature from the use of this drug was that
no chill was experienced in any of the foregoing cases, and in
all, especially in the operation for phimosis, its marked haemo-
static action was readily apparent.
Case IV. — This patient was also an adult, but with an ulcer
of the rectum. He was a man of forty-two years. The an-
aesthesia in this case, however, was a failure, the effect was nil,
and the patient complained of pain all through the operation.
The mucous membrane of the rectum was painted with a four-
per-cent. solution as high up as could be reached. No hypo-
dermic was employed. After waiting for twenty minutes for
the anaesthetic to take effect, the operation was commenced.
The patient complained that he felt the pain just as keenly as if
nothing had been used. The non-success of the drug in this
case was attributed to two causes: first, that the preparation
used was of American manufacture, whereas in all the former
cases the foreign make had been used ; secondly, to the much
greater difficulty of properly applying the drug to the mucous
membrane on account of the locality. The doctor finished the
operation while the patient uttered maledictions on the drug.
Dr. Wackerhagen remarked that he preferred not to use it
in the case of children, for the reason that it would be impos-
sible to keep them still enough to operate with any degree of
satisfaction, even when absolutely no pain was produced.
Case V. — This was the case of a man, thirty-two years of
age, affected with urethral spasm, who was taken to New York
to see Dr. Fessenden N. Otis. He also had a stricture. Dr.
Wackerhagen demonstrated to Dr. Otis that a No. 7 sound was
344
SHATTUCK : THE HOME TREATMENT OF PHTHISIS.
|N. Y. Mbi>. Jock.,
firmly held in the urethra by the spasm. After removing the
No. 7 sound, however, and injecting about thirty minims of the
hydrochlorate of cocaine and waiting for an appropriate length
of time, a No. 28 sound would slip out and in easily. Several
other New York surgeons were present and witnessed the
operation, which was eminently successful in two ways: first,
by proving that the drug could relax spasm, and, secondly, that
there are sometimes strictures with spasmodic complications.
For notes of the two following cases I am indebted to
the kindness of my friend, Dr. A. H. P. Leuf :
Case VI. — This patient was a young man with an old seba-
ceous cyst, located over the middle of the right sterno-mastoid
muscle. The offending body was inflamed and pointing, and
surrounded by a wall of inflammatory new formation about half
an inch thick. The skin was repeatedly painted with a four-
per-cent. solution of the hydrochlorate of cocaine for some time
before operating. Five minims were injected hypodermically on
either side of the sac. The anaesthesia produced here was so
very superficial and unsatisfactory that the operation was con-
cluded under ether. It is possible that a stronger solution might
have been used with a better result.
Case VII. — This was the case of a young English surgeon,
from whose tarsal cartilage Dr. Leuf removed a small tumor.
This tumor was of about the size of a pea. The cutaneous sur-
face of the upper eyelid was thoroughly painted with the solu-
tion, by means of a small brush, several times before the opera-
tion was commenced. The incision was made and the cocaine
was continually applied, waiting by spells for the anaesthetic to
take effect. He proceeded very slowly with the operation,
which he was compelled to do in consequence of these inter-
ruptions, and, after all the care that was exercised in this case,
much pain was evinced, and the anaesthesia was very unsatis-
factory. Dr. Leuf stated that under the influence of ether the
operation ought not to have taken more than five minutes,
whereas with the cocaine it took nearly an hour, the pain being
felt almost as acutely as if no anaesthetic had been used. No
hypodermic injection could be given on account of the locality.
The next and last two cases which I shall relate occurred
in my own private practice. These were more satisfactory
than those in which Dr. Leuf used the drug.
Case A7III was that of a youth nineteen years of age. The
operation was for phimosis. The foreskin was not so tightly
contracted but that the mucous membrane could be easily
reached with a fine camel's-hair brush and painted, which I did
very thoroughly with a four-per-cent. solution of the hydro-
chlorate of cocaine (Merck's). This was repeated several times,
and I waited for fully half an hour before operating, painting
the foreskin, both on the mucous membrane and on the cutane-
ous surface, at very short intervals during the whole half-hour.
I did not use any hypodermic injection in this case. I had given
the patient his choice before the operation whether he would
take ether or would have the cocaine, and he preferred the
latter. The pain he experienced was extremely slight during
the cutting part of the operation, the sutures causing somewhat
more, but not enough to give rise to any very serious discom-
fort. He said he greatly preferred it to ether, which he had
taken on a preceding occasion. The operation performed was
that of Professor Wight. I also noticed that the haemostatic
effect in this case was good. The haemorrhage was far less than
in those cases in which I have used ether as the anaesthetic.
Case IX was that of a lady who very much dreaded to go
under the influence of ether. The removal of a sebaceous cyst
from the scalp was to be the operation. I doubted the efficiency
of cocaine very much in this locality ; however, I resolved to give
it a trial, and, as I could not hope to produce any anaesthesia
from its external application, I accordingly injected with my
hypodermic needle fourteen minims of Merck's four-per-cent.
solution of hydrochlorate of cocaine. Seven minims were in-
jected at the anterior base and seven minims at the posterior
base of the tumor. I then waited for twenty -five minutes for the
cocaine to take effect. On making the linear incision, the pa-
tient felt some pain, and, as the spot was not a particularly sen-
sitive one, I doubted somewhat whether the cocaine had any-
thing to do with relieving the pain. However, on pulling out
the sac, I thought that the sensation was very much deadened.
She complained of some pain, it is true, but did not make half
the fuss I expected.
I have also applied cocaine to the mouth with very
good effect in one case. It was that of a child only a few
months old. It was teething, and I rubbed the swollen
gums with my index-finger, first moistened with the solution
of cocaine. The child appeared decidedly easier after a
quarter of an hour or so, and ceased crying after having it
applied a second time. My experience with cocaine has
been fairly satisfactory, and I shall continue to use it when-
ever I think it practicable.
There seems to be a goodly number of conflicting state-
ments with regard to its efficacy, but whether only apparent
or real remains to be demonstrated. It is said by some that
the American article is useless, and that the imported one
only is of use as an anaesthetic. One strong point in its
favor is, that in every case where it will take the place of
ether it does not leave the patient sick for hours afterward,
as is usual after the use of that anaesthetic.
It would also be an interesting point to learn just how
strong a solution could be used with safety to the patient
to avoid sloughing, gangrene, etc., which might possibly be
the effect if too strong a solution should be used, because
of its astringency and possible effect upon the trophic
nerves. Its application in medicine is likely to be far more
extensive than in surgery, and any method by which its
field of usefulness can be extended, whether by experiment
or otherwise, is certainly praiseworthy.
THE HOME TEEATMENT OF PHTHISIS*
By F. C. SHATTUCK, M. D.,
BOSTON.
About ten years ago, when making a visit in a French
hospital, I heard the epigrammatic professor say to those
who accompanied him : " For phthisis, gentlemen, there are
but two remedies, opium and lies." Of course he did not
mean his statement to be taken in absolute literalness, but
the remark affords a good illustration of the view which has
been held in the past by the profession and the laity alike,
but which is undergoing, and will undergo, further modifi-
cation. Let me quote what another French professor, M.
Jaccoud, says in his work, the English translation of which
has just appeared: "To sum up what has been stated, pul-
monary phthisis is curable in all its stages. This is the
prolific notion which presides over the whole history of the
* Read before the American Climatological Association, May 27,
1885.
•Sept. 20, 1885.J
SHATTUCE : THE HOME TREATMENT OF PHTHISIS.
345
disease, and which should unceasingly inspire and direct all
medical action." *
There is very little disagreement among doctors as to
the fact that the chances of recovery are much better for
patients so situated that they can have a suitable change of
climate, or, at all events, move from the city to the country;
but is removal indispensable to cure ? The experience of
nearly every physician in active practice answers this ques-
tion more or less conclusively. Dr. Flint has shown that a
certain proportion of the phthisical recover not only with-
out climatic, but practically without any treatment ; that in
some cases phthisis ends by self-limitation. But allow me
to dwell for a moment on the vital statistics of my own
State. In 1857, 39*50 deaths from consumption occurred
in Massachusetts for each ten thousand of the population ;
in 1883, 29-90, the diminution being gradually progressive
during this period, as is seen in the accompanying table
which I take from the registration reports. These figures
show a still larger decrease in the mortality from consump-
tion among the native population, for the decrease has taken
place in spite of the constant influx of foreigners, and nota-
bly of the Irish, who are proved, by the studies of the late
Dr. T. B. Curtis and others, to be especially prone to this
disease.f
Death-rate from Consumption in Massachusetts per Ten
Thousand.
1871 33-93
1872 36-26
1873 35-36
1874 32-80
1875 34-73
1876 32-35
1877 32-93
1878 32-00
1879 30-42
1880 30-81
1881 31-50
1882 30-10
1883 29-90
1857 39-50
1858 38-42
1859 38-85
1860 37-02
1861 36-77
1862 34-28
1863 . . 37-26
1864 37-89
1865 36-79
1866 35-33
1867 32-55
1868 32-20
1869 32-88
1870 34-33
This decrease is altogether too large to credit to greater
accuracy in diagnosis and to the transference of consump-
tives to other States, but is mainly attributable to the pre-
vention of phthisis by improved hygiene, especially among
the native-born. Still it seems to me fair to carry some of
the improvement to the account of the arrest and cure of
actually developed disease through early diagnosis and more
rational home treatment, hygienic as well as medicinal.
There are two classes of consumptives for whom the
home treatment is the only treatment — those whose means
do not allow a change of climate, whatever the condition or
stage of their disease, and those whose condition is such
* " Curability and Treatment of Pulmonary Phthisis," translated by
Lubbock, pp. 27 and 28.
f For full details on this latter point, which it is impossible for me
here to further develop, I must refer to the very able "Report on the
Sanitary Condition of Boston," written by Dr. Curtis in behalf of a
medical commission appointed by the city. The report was published
by the city in 1875.
that, whatever their means, they had better stay at home and
die among their friends, surrounded by the comforts which
are to be found in the homes of the well-to-do, but which
can so rarely be secured, especially in this country, in hotels
or boarding-houses. It is true that some of the latter class,
buoyed up by the hopefulness so often characteristic of this
disease, will not be said nay, and succeed in finding a
physician who counsels a change or else take the matter
into their own hands ; these do not, however, immediately
concern us. Nor does it come within the scope of my
paper to discuss the questions as to the rules which are to
guide us in selecting cases for which a change of climate is
desirable, or in selecting a climate for any particular case.
The fact remains that the vast majority of consumptives
must, perforce, remain at home. How can we best aid the
recovery, prolong the life, and alleviate the sufferings of
these patients ?
I have no novel or startling views to lay before you, and
shall probably not be able to tell you anything which you
do not know already. In the discussion which follows the
paper, if not in the paper itself, there will be valuable sug-
gestion. What I have to say is, of course, without special
reference to the particular climate which may belong to the
home of the can't-get-away consumptive.
The consideration of the treatment of phthisis falls
naturally into two great divisions, the hygienic and the
medicinal; let us take up the more important first, includ-
ing under hygiene food, morals, fresh air, rest and exercise,
dress, and bathing.
Phthisis (or the tubercular bacillus, if you will) resem-
bles one of those weeds which grow only on poor or neg-
lected soil, but it also exhausts completely what measure
of virtue the soil may have ; hence, by every means at our
disposal, we should seek to improve the general health of
our patients, that we may aid nature in choking out the
disease. The key to the position in the present state of
our knowledge is in attention to digestion. A patient
of mine, a brilliant example of complete recovery, said to
me: "As long as my stomach held out I was not very anx-
ious." Every consumptive should eat the maximum amount
of nourishing food which he can digest — which he can di-
gest, let me repeat — for, as Lauder Brunton pithily says, we
should always remember that food within the gastrointes-
tinal tract is still practically outside of the body. There
are general laws of dietetics, and we know how long it took
the stomach of St. Martin to deal with many different arti-
cles of food. Certain materials and certain methods of
preparation agree better than others with the majority of
mankind ; but in dealing with patients we give our advice
to individuals, not to men or classes of men collectively.
In dietetics, as in a Western mining camp, every man is in
large measure a law unto himself. I am often reminded of
a wretched child suffering from congenital syphilis and
rickets, among other things ; the bowels were loose, did
not improve readily under treatment which I considered
to be suitable, and the weather was characteristic of the
season — summer ; so I sent the child and its mother to a
healthy place in the country, with careful directions as to
diet and drugs. After some weeks the mother returned
346
SEATTUCK: THE HOME TREATMENT OF PHTHISIS.
[N. Y. Med. Jocr.,
with more of a child than she took away, and, on question-
ing her, I learned that for a time she conscientiously fol-
lowed my directions, but was not rewarded by seeing any
improvement ; blueberries were plenty in that part of the
country, the child craved them, the mother with misgivings
gave them, and the diarrhoea promptly ceased. Our dis-
tinguished member, Prof. Flint, says, in writing of dyspep-
sia, that sufferers " must follow the dictates of instinct rather
than any precise rules." I was delighted to find this war-
rant for the assent which my far more limited experience
has led me often to accord to the request of patients, and
particularly consumptives, for special articles of food, how-
ever bad the reputation of such articles as regards digesti-
bility might be ; never in the case of a consumptive have I
had reason to regret the indulgence. I think we are per-
haps oftener called upon to give minute directions as to the
frequency with which food is to be taken than as to the
form which it is to assume. Much more work can often be
got out of the stomach without remonstrance by five, six, or
seven light meals a day than by three heavier ones. A
glass of milk or the like, with or without a raw egg, and a
little alcoholic stimulant, midway between meals and at
bedtime, may be of more service than anything contained
in the drug-shops ; and a cup of hot bouillon, as soon as
possible after waking, will carry a patient over his morning
cough, bath, and toilet, with a good appetite for breakfast.
I have repeatedly seen this simple expedient make a great
difference in the comfort of the whole day.
'Alcohol, in such form and quantity as careful observa-
tion of the individual patient shows is best tolerated, is indi-
cated in most, though not in all, cases. Any toxic effect is
to be avoided, and the influence on the appetite and diges-
tion is to be watched ; there is room for the exercise of
much judgment in the use of this form of food, and that a
certain amount of alcohol is, under certain conditions, a food,
I have myself no question.
With forced feeding after the manner of Debove I
have no personal experience, and dismiss the subject of diet
with the repetition of the axiom that in phthisis the physi-
cian should see to it that his patient takes all the nourish-
ment he can digest.
The moral management of the case requires a few words.
Here there is scope for the most delicate tact and the most
intimate knowledge of human nature. Some patients need
to be frightened, some to have their fears allayed. Let
science clarify and sharpen our vision ; let it not render us
so hypermetropic that we do not see distinctly the individu-
al in the patient before us. I think we are sometimes in-
clined to fofget what a powerful therapeutic agent progno-
sis may be. Let us give the patient the benefit of every
doubt, remembering that the prognosis represents our opin-
ion, not inevitably the truth. An unfavorable opinion should
often be reserved for a near and judicious friend, if the pa-
tient be so fortunate as to have one. All patients are not
so tenderly considerate of their physician's mistakes as was
the young lady who recovered after she was given up by
her doctor, and ever thereafter, when she met him, blushed
for shame. Occupation is another branch of moral treat-
ment which must not be lost sight of.
Dress need not detain us long. Consumptives are apt
to err on the side of too many and too heavy clothes, keep-
ing the skin in perpetual action and wearying the body by
mere weight. The ordinary house-dress of the average
man in our climate in the winter season weighs eight to ten
pounds. Let the consumptive wear wool or silk next the
skin from the neck to the toes, and let him change them
frequently ; a change of stockings several times in the day
will often obviate the discomfort of cold feet. It is im-
portant, especially with the poorer class of patients, to in-
sist on wool, and warn them not to allow the shopkeeper
to pass off a cotton for a woolen garment.
Too much stress can scarcely be laid on the importance
of fresh, pure air. Carbonic acid and carbonic oxide are
poisonous enough to well people, but how vastly more dele-
terious to those suffering from a constitutional disease
manifesting itself in the lungs! Fortunately, sounder ideas
prevail on this point than was formerly the case, but there
is still room for improvement. The apartments occupied
by the patient should face the south if possible ; it seems
to be thought by some that the exposure of a bedroom is
of no consequence, as if a third of the life of a healthy
person were not passed there. An open fire of wood or soft
coal should be kept up in the living-room if possible, and
ventilation should be carefully provided for. In severe or
windy weather a simple frame fitted to the window and
covered with flannel can be put in at the top, a weather-
strip on the lower edge of the upper sash preventing the
rush of cold air which would otherwise occur between the
sashes. Fresh air can thus be constantly introduced with-
out causing any appreciable draught. Equal solicitude
should be given to the ventilation of the sleeping-room. I
am often struck by the appearance of the houses in our
most fashionable streets. In streets running east and west
land is apt to be higher in price on the north side, which,
of course, alone gets any sun during more than six months
of the year. Of shades and curtains there are often half a
dozen series, and during the forenoon the shades are pulled
down and fastened at the bottom that the precious furniture
and carpets, more highly valued by the owner than health,
may not be faded ; the sun is paid for and then excluded
for the sake of the furniture. Those who can not afford
delicate fabrics are better off.
So much for fresh air and sunshine in the house. Fresh
air without the house is naturally considered in connection
with exercise. We should insist on out-door exercise in
such degree and form as the strength of the patient, the
length of his purse, and the season will allow. Driving
should, if possible, be in an open vehicle, which for a weak
person should have a high back, and in windy weather a
veil or a respirator should be worn by the occupant. People
are finding out that sleighs are not the only open convey-
ances which can be used in winter. I believe that with
proper precautions there is, as a rule, more risk of catching
cold in a close than in an open carriage. Exercise in the
saddle, if desirable or practicable, has the great advantage
over walking that it distracts the mind as well as uses all
the muscles.
We find that a certain number of those who consult us
Sept. 26, 1885.] ^ SHATTUCK: THE HOME TREATMEN1 OF PHTHISIS.
347
have been doing too much. I have repeatedly seen fever
greatly diminish or cease entirely after putting the patient
to bed, with abundance of fresh air, for a few days. It is
not enough to tell patients to avoid over-fatigue ; very few
know what this means. I often try to explain somewhat as
follows : " A fatigue which passes away after resting an
hour or so on the completion of your exercise is natural and
healthy, and therefore does you good rather than harm ; but
if you find that, in spite of a reasonable rest, you are still
tired, you have done too much." Such a rule I believe to
be safe.
There is a popular idea that there is something about
the night air which is particularly dangerous to consump-
tives— an idea which, like many of those bearing on medi-
cine and current with the laity, probably came originally
from the profession, which advances in knowledge faster
than the public. The night air is all the air there is at
night, and iu non-malarious regions the danger of going out
in the evening does not lie in the quality of the air, but in
the fact that persons are at that time often tired and, conse-
quently, more sensitive to alterations of temperature, or any
other demand upon the vital forces ; the bearing of this
observation is sufficiently patent.
The character of the employment of the consumptive is
also to be borne in mind, and an out-of-door occupation, in-
volving no severer toil than the patient can stand, should
be followed if possible. Too often this is impossible ; but
we must do the best we can under the circumstances.
Patients who are too weak to take any active exercise
often derive great benefit from a sun- and fresh-air bath. In
the country a little shed can be built, open toward the south
and sufficiently deep to keep off the wind from the patient
sitting in a chair or lying on a mattress. In the city an
easy-chair can be placed near a widely opened southerly
window. The invalid should have as many blankets or
robes as he wishes. No matter how low the thermometer,
if the sun shines brightly there is rarely any difficulty in
keeping warm, and a small sun-shade or similar contrivance
is often needed to protect the head. No artificial heat has
the penetrative power of the sun, and I have repeatedly
found patients, who were horrified at the idea when first
presented to them, enthusiastic in their expressions of satis-
faction at its practical working. In city streets people often
object to this measure from a fear of appearing peculiar to
their opposite neighbors or passers-by. I have found it a
most valuable means of treatment for those who are debili-
tated from any cause.
Gymnastics, with the view of expanding the chest and
promoting the absorption of diseased products in the lunos
through the improved circulation thereby brought about?
have perhaps not received so much attention from the
regular profession as they deserve. Of course, exercise of
any kind quickens the circulation ; but this is not clearly
understood by the laity, and the imagination is more excited
by means which are manifestly directed immediately to the
seat of the disease. Respiratory gymnastics have thus a
double value, and precise directions are more likely to be
followed than those which are purely general. I know of a
" doctor " who has apparently found it very profitable to I
teach people how to breathe, and I do not doubt that some
of his patients have found it profitable to learn ; he thus
prevents and cures consumption, reduces the weight of those
who are too fat, and augments that of those who are too lean.
A grain of truth is none the less precious because it is cov-
ered with an investment of quackery.
Another and the last branch of hygiene on which I
shall touch is bathing. Cleanliness is desirable in itself,
and it is quite as important for the phthisical as for the
healthy to maintain a proper action of the skin. After a
warm bath, unless it is followed by a cold douche, exposure
to cold is to be carefully guarded against. A cold bath is
a powerful tonic; but how are we to determine in a special
case the proper temperature ? Of course, in many cases
cold baths are out of the question, but probably not in as
many as is generally supposed. It is the reactive power of
the patient rather than the thermometer which should de-
cide the temperature of the cold bath ; the colder the better,
provided that thorough, prompt, and persistent reaction
follows, promoted by a brisk rubbing with a coarse towel
or a flesh-brush. The use of a cup of hot bouillon before
the bath has already been alluded to, and reaction may
often be further aided by the addition of rock salt or some
other cutaneous stimulant to the water. That the syste-
matic study of hydro-therapeutics as one of our weapons
against debility will receive more attention in the future
than it has in the past, I have no question.
The medicinal treatment may be divided into the gen-
eral or curative, and the symptomatic or palliative, the
object of the former being to stimulate and improve the
general nutrition, that of the latter to check as they arise
such symptoms as militate against the recovery or the com-
fort of the patient. Such a division may be artificial, but>
for our present purposes, is convenient.
If we always bear clearly in mind the fact that our aim
in giving general medicinal or tonic remedies is simply to
promote assimilation, and thus put our patients into a con-
dition more favorable to recovery or less favorable to the
rapid advance of their disease, among other advantages we
are apt to choose more judiciously the special form of tonic
which is most likely to be of service. Cod-liver oil, either
pure or in one of the numberless disguises which it is made
to assume, and some of which certainly have their places,
needs no commendation from me. It is, perhaps, a food
rather than a drug ; but a food which demands a certain
amount of digestive power, and we all see it prescribed when
it does more harm than good, for the very simple reason
that digestion is not equal to it. With many physicians the
diagnosis phthisis is followed by the prescription oleum
morrhuae as the thunder follows the liiditnino;. " The doc-
tor told me to take cod-liver oil, but I can't keep it on my
stomach," said a feverish young girl without appetite who
consulted me only yesterday. In my experience this rem-
edy is generally to be avoided if the tongue be coated
and the appetite poor; if, in addition, there be fever, the
case is still clearer. The fever requires always fresh air,
often rest, with quinine or another antipyretic, and the
stomach a bitter tonic, as a rule, combined or not with a
laxative, according to circumstances. After a week or two
348
SHATTUCK: 7 HE HOME TREATMENT OF PHTHISIS.
[N. Y. Med. Jock.,
of such treatment the appetite and digestion are often so
much improved that cod-liver oil is home. If there is any
doubt as to its toleration, it is better to begin with tea-
spoonful doses and gradually increase to the full dose as
warrant is found for doing so, the full dose being much
larger than most of us have been in the habit of using, if
the views of Jaccoud are correct. If the pure oil is well
borne, I believe it to be better than the more palatable
though weaker preparations, and the remedy is not to be
thrown aside without a fair trial, inasmuch as a stomach
which is rebellious at first sometimes accepts the situation
with apparent cheerfulness after a few days' cautious per-
suasion. It is not needful that I should enumerate or dwell
upon the various emulsions, etc. ; the advertising pages of
our journals, circulars, and the periodical visits of the
affable gentlemen with hand-bags, remind us of them some-
times in moments when we would fain forget them. The
fact remains that cod-liver oil pure, or never so skillfully
emulsified, is worse than useless unless it can be digested ;
if it can be digested, it is a most valuable form for the ad-
ministration of fat, a material which long and wide experi-
ence has shown to be especially indicated in consumption.
Jaccoud recommends highly glycerin, | jss.-ij daily, as
a substitute for cod-liver oil when there is fever.
Ferruginous tonics are sometimes of use for short periods
if there is notable ansemia, but are contra-indicated by a
coated tongue and sluggish bowels. Arsenic, on the other
hand, either in solution or pill, has a much wider application
than iron in phthisis, and should often be continued for
long periods. The dose should be as large as is perfectly
well borne, and it is sometimes well to omit it for a week
and then resume. It interferes in no wSy with the admin-
istration of cod-liver oil or glycerin. The diastatic tonics
and the hypophosphites also have their place, and often
seem distinctly to aid a feeble digestion, thus contributing
toward a gain in flesh and strength.
The leading symptoms which call for interference, and
to which I shall briefly call your attention, are cough, pain,
night-sweats, diarrhoea, and hectic with its attendant nerv-
ousness.
Patients often say to us, " Doctor, I have taken your
medicine, but my cough is no better," the cough represent-
ing to them the disease. In a semeiological sense they are
largely right, but in a therapeutic sense very far wrong.
"When the cough ceases entirely the patient is at the door
either of recovery or death ; but we know, even if our
patients do not, that, as long as there is mischief in the lung,
cough must persist. How often do we sec consumptives
who, generally on their own notion or acting on the sug-
gestion of friends, but, unfortunately, sometimes in accord-
ance with medical advice, are taking cough mixtures to
their detriment ! In advanced cases, which must sooner or
later prove fatal, such an error is of less consequence ; but
in early cases the effect on the appetite and digestion is
often disastrous. Coughing may be very hard work, but
before we interfere with it there is one main question we
should ask ourselves: Is the cough in the case before us
useful or needless ? I speak of cases relatively, not abso-
lutely. A cough which is followed by expectoration is not
entirely in vain, while that which is simply irritative wears
out the patient. The former is not to be checked by any
means which involves the risk of impairing the digestive
power unless it provokes vomiting or breaks up the night's
rest, which is of such vital importance that we are justified
in seizing the two-edged-sword opium to obtain it if milder
means fail. The surest way to diminish excessive expecto-
ration is to pay close attention to hygiene and diet, though
suitable inhalations will sometimes help. The type of the
useful cough is that which occurs on waking in the morn-
ing, and which clears out the secretions that have accumu-
lated during the superficial respiration of sleep. The value
of a hot drink, which with a spirit-lamp at the bedside and
five minutes' time is ready, as an expectorant at this time
has been already spoken of. If this is not sufficient, a little
alcohol or a stimulating expectorant, like carbonate of am-
monia, can be given in addition.
The teasing and irritative cough, on the other hand, it
is our duty to check if we can, but by the mildest means at
our disposal which will accomplish our object. Oftentimes
I have found chloroform-water stand me in good stead ;
but there are cases in which the narcotics, and especially
morphia, must be used ; the great danger of morphia is that
it is so efficient in relieving cough that we are tempted to
use it indiscriminately, thus doing great harm. One of the
most distressing forms of cough met with in the phthisical
is that hard variety which leads to vomiting, consuming
the patient like a candle lighted at both ends ; this gener-
ally calls for opium in some form, though it is well to try
the effect of an alcoholic stimulant first. Especially in
those cases with sharply localized pulmonary lesioDS, coun-
ter-irritation over the seat of the disease will often econo-
mize drugs and the stomach alike. The ammonia blister is
a favorite form with me.
For the thoracic pain which is apt to be more or less
pronounced at times in nearly all advanced and some early
cases, and which is sometimes rheumatic or neuralgic, some-
times pleuritic, we are called upon to prescribe. Counter-
irritation with mustard, chloroform, a liniment, croton-oil,
and the like, generally proves sufficient, though here again
we are sometimes forced to use opium. When the pain is
fairly localized I find that the application of a dry cup or
two, a simple remedy which has gone too much out of fash-
ion and of which any untrained attendant can readily be
taught the use, is often followed by marked relief.
Another symptom which demands interference is night-
sweat, sapping the strength of the patient and marring his
sleep. Sometimes it is a very easy matter to control this
overaction of the skin, sometimes it is very difficult. Hence
it is well to have many strings to our bow ; we are not in-
frequently compelled to try successively aromatic sulphuric
acid, oxide of zinc, ergot, atropia, quinine, or Dover's pow-
der internally, or dusting powders, sponging with acids,
alkalies, alcohol, or tincture of belladonna externally, before
we meet with success. If the patient can bear it, active
friction or shampooing of the skin is often desirable. I
have given a good deal the pill used in the Victoria Park
Hospital containing morphia and atropia, combined with a
little capsicum and a laxative if required ; night-sweats and
Sept, 26, 1885.]
SEATTUGK: THE HOME
TREA TMRNT OF PHTHISIS.
349
cough arc both controlled by it, but my objection to atro-
pia lies in the difficulty of so adjusting the dose that the
desired effect on the skin is obtained without producing an
undesirable degree of dryness of the throat. In two cases
I have succeeded with picrotoxin after having tried in vain
every other remedy of which I could think.
There can be no more question as to the propriety of
trying to relieve diarrhoea than there is with regard to pain
and night-sweats. When the loose discharges depend on
ulceration, and still more when they depend on amyloid
disease of the intestine, they are apt to be difficult to re-
strain ; and yet in some cases of tubercular, as of typhoid
ulceration, so far from diarrhoea being present, there is con-
stipation. It is needless to say more than that the treat-
ment is by astringents and opium, the particular remedy in
any given case depending on the urgency of the symptom,
trial, and any known peculiarity of the patient, In cases
where there is any hope of recovery, if we give opium we
should strive, while we give enough to attain our end, to
give no more than is necessary.
For nervous irritability, whether manifested by a wor-
ried but healthy adult, a teething child, or a phthisical per-
son, a plentiful supply of cool, fresh air is the first indication.
Against the fever of phthisis antipyretics have, as far as
I know, been but little employed in this country. I cer-
tainly have made no systematic use of them myself. The
fever is not the disease, and the cases must be very rare in
which a diminution of the pyrexia for a few days may make
all the difference between recovery and death, as is some-
times true of the more acute infectious diseases. At the
same time fever works to the detriment of the patient in
two ways — diminishing his income and also squandering
his capital. Therefore, if we can combat it without destroy-
ing what little digestive power it is apt to leave, clearly our
duty is to do so, and I propose to give the method which
Jaccoud thinks has yielded him admirable results a thor-
ough trial. It is perhaps scarcely fair, either to him or to
you, to try to describe in a few words what his method is ;
but the gist of it is the administration of large doses of
quinine for inflammatory fever by the mouth or under the
skin, the hydrobromate being always chosen for the latter
avenue of introduction into the system, while for the fever
of absorption large doses of salicylic acid by the mouth
or salicylate of soda hypodermically, if the stomach is ir-
ritable, are chosen. Whether we shall all find it as easy to
differentiate the forms of fever in phthisis as does Jaccoud
I do not know, but the subject of fever is far too large for
our present opportunity.
My slight sketch of the home treatment of consumption
is now finished. The different aspects of the question
afford material for a dozen detailed pictures, and there are
two important lines of treatment of which I have purposely
omitted all mention — inhalation, notably by antiseptics and
oxygen, and the use of artificially compressed and rarefied
air. Perhaps I am wrong, but the published reports of the
experience of Pepper, Beverley Robinson, and others, has
not encouraged me to try antiseptic injections into the
lungs ; nor have I ever practiced the free incision and drain-
age of pulmonary cavities.
DISCUSSION.
Dr. P. KRETzscnMAR indorsed the remarks of Dr. Shattuck.
There were some points which perhaps deserved further con-
sideration. One related to the sleeping-room. As we all knew,
one third of the time of every human being was spent in the
sleeping-room, and he therefore thought that more attention
should be given to this matter in the hygienic treatment. He
had in mind particularly the question of the size of the sleep-
ing-room, the question of the consumptive sleeping with other
persons, and the question of leaving the windows open at night.
The home treatment of consumptives related especially to the
poor, and here we were apt to find five or six persons sleeping
in a small room badly ventilated. He thought more could be
done by the administration of pure air if attention were given
to the ventilation and size of the sleeping-room, where the pa-
tient spent a third of his life, than by other means. He, of
course, approved of the author's remarks concerning the ven-
tilation of the sleeping-room during the day. The second point
was, Should we not advise our patients, especially those inclined
to phthisis, against sleeping with others? A third point was,
we did not usunlly pay sufficient attention to the frequent and
thorough removal of the sputa from the sleeping-rooms. In
addition to the remedies mentioned, he recommended cold sage-
tea before going to bed.
Dr. Robinson said he did not wish in any wise to criticise
the paper as far as it went, for he agreed with Dr. Armour, who
considered the paper an admirable presentation of the subject,
but he regretted that the author had not mentioned three
modes of treatment which he believed physicians might find of
advantage in the treatment of phthisical patients at their homes
after other methods had failed. The first was forced feeding,
giving patients more food than they craved, and even more than
the stomach could digest if the food was swallowed. The sec-
ond method related to intra-pulmonary injections ; the third to
antiseptic inhalations, with regard to which he had presented
his views in a paper to-day. These methods had been tried in
St. Luke's Hospital during the past winter. A young man
came into the service of Dr. Ball six or eight months ago, after-
ward into Dr. Kinnicutt's service, and finally into his (Dr.
Robinson's). On admission, there was evident pulmonary infil-
tration at the apices, and the stomach was absolutely intolerant
of the smallest quantities of food. Nearly everything was
vomited. By washing out the stomach and pouring food into
it through a soft tube they were enabled to give the patient nu-
triment, and increased his weight at least six or seven pounds.
Beyond this increase in weight, the patient's phthisical condi-
tion was in no sense ameliorated. We had to take such a case
for what it was worth. We certainly could not take it as show-
ing that phthisis was made better even by improved nutrition ;
but it showed that we could increase the patient's weight and
thus better his condition.
With regard to injection of infiltrated lung areas, he could
only repeat what he had before endeavored to emphasize,
namely, that there were certain cases in which we were unable
to arrest cough by other means, while this treatment benefited
cough and local congestion.
One more word, which he knew to be heterodox, but which
he believed nevertheless to be true. He had had charge of a
good many phthisical patients at the Out-patient Department of
the New York Hospital, and he could say that certainly very
few of those persons having infiltration of the lungs were bene-
fited to any considerable degree by ordinary methods of treat-
ment.
Dr. SnATTUOK, in closing the discussion, said he cordially
agreed with all Dr. Kretzschmar had said. He had found it
350 HARD AW AT: TEE RADICAL
hard to tell, in so short a paper, what to say and what to leave
unsaid. With regard to what Dr. Robinson had said concern-
ing forced feeding, he was glad ti hear about it, and to know
that it had been tried in New York. He had not mentioned it
in his paper because he had had no personal experience with it.
Inhalations and treatment with compressed and rarefied air he
had left out purposely, because they were large subjects and he
knew there were to be papers specially devoted to their con-
sideration. With regard to injections into the lungs, he had
read one paper on the subject by Dr. Robinson, and the im-
pression which he got from it was that he did not do the pa-
tients any harm, but he could not say that he did them any
good, and it was not pleasant to have the Deedle stuck into one
unless it promised some good result.
THE EADICAL TREATMENT OF SYPHILIS.
By W. A. HARDAWAY, M. D.,
ST. LOUIS.
The article in this journal for July 11th, by Dr. Leuf,
on the " Eradication of Syphilis during the First Stage by
Surgical Means," will perhaps recall the fact that a paper
of similar import was published by me in the " New York
Medical Journal " for December, 1877. In von Ziemssen's
" Handbuch der Hautkrankheiten," Neisser, in the article
on syphilis, credits my paper on the extirpation of lymphatic
glands in the radical treatment of syphilis to the " Ameri-
can Journal of the Medical Sciences" for 1877.* As a
matter of fact, however, this subject was presented by me
originally in the shape of a thesis for graduation in the year
1870. It was subsequently published in the "St. Louis
Medical and Surgical Journal " for May, 1872, then enlarged
and read before the American Dermatological Association
in 1876, and afterward printed in the "New York Medical
Journal," as stated above.
Before concluding, I should like to trespass on your
space for a few general statements. Hill's case, well known
to syphilographers, in which he cauterized a laceration of
the frsenum, made during violent intercourse, twelve hours
after its occurrence, and with a negative result as to preven-
tion of systemic infection, together with the oft-quoted in-
utility of the complete destruction of the vaccinal bouton,
have been paraded time and again as proofs, both positive
and analogical, of the utter futility of any local measures in
the suppression of constitutional symptoms. While I am
far from denying that the complete and sufficient destruction
of the initial lesion, at the right time and in the right way,
may, under certain circumstances, avert general syphilis, still
I long ago said : " I believe that in a certain number of
cases destruction of the initial lesion would prove futile, as
I am of the opinion that the virus is soon carried to the
lymphatic glands, as is evidenced by these glands undergo-
ing the same processes as obtained in the primary sore, and
this would explain why total destruction of the inoculated
parts has generally proved unavailing." In the section on
treatment, in the paper referred to, which I shall take the
liberty of quoting at length, I made the following state-
ments :
* The whole title of the paper is " The Lymphatic Theory of Syphi-
litic Infection ; with a New View of the Relation between the Chancre
and Chancroid, and Suggestions for the Treatment of Syphilis."
TREATMENT OF SYPHILIS. [N. Y. Med. Jouk.,
" As a logical result of the views which have been ex-
pressed as to the pathology of syphilis (that is, absorption
by the lymphatics), it has long seemed to me that an early
extirpation of the enlarged lymphatic glands contiguous to
the initial lesion would in some instances avert constitu-
tional infection. This would certainly be, to say the least,
as legitimate an operation as excision of the chancre itself,
which is looked upon favorably by some excellent authori-
ties, although, even from my standpoint, I would regard
this latter procedure as generally unavailing for reasons
already given. By writers such as Lee, Lancereaux, and
others, who do not deny that the syphilitic virus is carried
to the glands by the lymphatic vessels, this operation might
still seem to be justifiable, as depriving the blood of one of
its sources of infection. While not bearing directly on this
subject, but still of interest in this connection, we find Nie-
meyer writing that ' it is quite possible that at no distant
day the danger of pulmonary tubercle, which the presence
of the cheesy residua of enlarged glands produces, will take
a place among the indications for the extirpation of peri-
pheral lymphatic tumors.' It would be advisable to remove
enlarged lymphatics following the initial sclerosis at the
earliest period practicable, when they had first begun to in-
durate. . . . Again, if it be admitted that lymphatic glands
remain as foci of infection, ... it would not be bad prac-
tice to remove them."
Some years after the foregoing was first written I had
the good fortune to read the very remarkable papers by M.
Raynaud, entitled, " Recherches experimentales sur l'infec-
tion et l'immunite vaccinales," "Gazette hebdomadaire," No.
29 et seq., tome xvi, 1879. These experiments of the late
distinguished French physician, which seem to be little
known, but, so far as I am aware, never contradicted, appear
to my mind to be conclusive so far as vaccinia is concerned,
and also by a logical analogy for syphilis. As I have already
occupied too much of your valuable space, I shall content my-
self with merely giving an outline of Raynaud's experiments.
Raynaud has demonstrated (a) that the virus of vaccinia is
conveyed to the system at large by way of the lymphatics ;
and (b) that extirpation of the vaccinal bouton alone is in-
effectual as regards general infection, but that this end is
completely gained when (for reasons that he clearly indi-
cates) both the contiguous glands and the vaccinal lesion are
suppressed.
rjflh Jftotites.
BOOKS AND PAMPBLETS RECEIVED.
Fownes's Manual of Chemistry, Theoretical and Practical.
A New American, from the Twelfth English, Edition, embodying
Watts's " Physical and Inorganic Chemistry." With One Hun-
dred and Sixty-eight Illustrations. Philadelphia: Lea Brothers
& Co., 1885. Pp. xxx-1056.
The Management of Labor and of the Lying-in Period. A
Guide for the Young Practitioner. By Henry G. Landis, A. M.,
M. D., Professor of Obstetrics and Diseases of Women in Star-
ling Medical College, etc. Philadelphia : Lea Brothers & Co.,
1885. Pp. viii-334. [Price, $1.75.]
Sept. 2G, 1885.]
LEADING ARTICLES.
351
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Poster, M. D.
NEW YORK, SATURDAY, SEPTEMBER 26, 1885.
THE INTERNATIONAL MEDICAL CONGRESS.
We are close upon the termination of the period of thirty
days that the New York meeting of the American Medical As-
sociation's committee laid down as the time within which it
would receive back into the fold any of the gentlemen who had
declined to figure in its organization of the International Medi-
cal Congress, but who might be willing to withdraw their
declinations. In the course of a week from now the period
alluded to will have all but expired. So far as we know, only
one person has seen fit to respond to the committee's overtures,
while, on the other hand, the work of declination is steadily
going on, and, as will be seen by announcements elsewhere in
this issue, has been taken part in latterly by some of those to
whose continued support the committee must have attached the
utmost importance, and upon which it must have counted quite
confidently. Not only has the committee thus signally failed
to recall those who declined to share its fortunes, and to pre-
vent others from joining them, but it is plainly evident from
the expressions made use of in the committee's official report
of its proceedings that it has at last come to recognize the fact
that it must proceed with great caution in the work of making
•appointments, lest it may appoint gentlemen only to find them
declining at the earliest opportunity.
It is manifest, therefore, that the committee has utterly
failed to repair in any degree the breach of concord which its
creation precipitated upon the American profession, and which,
in the view of the great majority of well-informed and fair-
minded men, has entirely done away with the possibility of a
successful meeting of the Congress in this country in 1887. It
was not to be expected that the committee would be able, even
if it was willing, to take measures calculated to restore the
harmony necessary to success ; for it could not, of course, go
counter to the implied instructions under which it acted. Hav-
ing done its best to carry out those instructions at its Chicago
meeting, it might at one time, when its efforts were first shown
to have demonstrated the impracticability of reconciling the
American Medical Association's usurpation with the possibility
of a successful meeting of the Congress, have gracefully de-
clined to proceed further in its thankless task. Instead of do-
ing so, it chose to indulge in further attempts to accomplish
the impossible, and it also took occasion — or occasion has been
taken in its behalf — to inform the profession that its (the com-
mittee's) course was in no sense a compromise. Compromise
it certainly was not, nor was it in any way conciliatory. As
the committee, therefore, has no disposition to conciliation, it
is useless to expect now that it will under any circumstances
admit that its creation was detrimental to the proposed Wash-
ington meeting of the Congress. The question arises, then,
whether it is incumbent upon the officials of the Congress to
wait much longer before withdrawing the acceptance of the
American invitation. Our own conviction is, that both the in-
terests of the Congress and those of the American profession
would be decidedly furthered by prompt action on the part of
our European colleagues.
MINOR PARAGRAPHS.
THE NEW BRITISH PHARMACOPOEIA.
From the comments of our London contemporaries on the
new British Pharmacopoeia, we learn that certain changes of
nomenclature have been made which bring it into close con-
formity with our own pharmacopoeia, especially in the matter
of the proximate principles of vegetable drugs. Such words as
morphia, strychnia, atropia, etc., have been given up, as was
done in our pharmacopoeia three years ago, and we trust that
they will soon disappear from medical writings. As with us,
the alkaloids are now to be known by names ending in -ina,
whilo the termination -inum is given to neutral principles. Now
that the British and the United States Pharmacopoeias are at
one on this point, and in accord with the practice of contem-
porary chemists, we trust that their example will soon be fol-
lowed in the pharmacopoeias of other nations. As regards no-
menclature, the oleates seem to have been put upon a different
footing from other salts with names ending in -ate, for, while
we read of sodii salicylas, sodii sulpho-carbolas, etc., we find
oleatum hydrargyri, and so on. Paraffinum durum and paraf-
finum molle, which we take to mean respectively paraffin and
" vaseline," seem to us to he preferable to our own terms for
those substances. Among the coca preparations we find cocainae
hydrochloras and lamella? eocaina?.
NEWS ITEMS, ETC.
Infectious Diseases in New York. — We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending September 22, 1885 :
DISEASES.
Weekending Sept. 15.
Week ending Sept. 22.
Cases.
Deaths.
Cases.
Deaths.
48
9
69
13
24
1
15
1
Cerebro-spinal meningitis. . . .
5
5
4
5
1
0
4
2
38
18
46
30
2
0
2
2
Small-pox in New York.— It is reported that a woman
suffering from small-pox was found in a house in Grand Street.
It is probable that other cases may result, as a number of board-
ers left the house as soon as the nature of the disease was dis-
covered.
Small-pox in Canada.— The United States Consul-General
reports to the secretary of the National Board of Health the
number of cases of small-pox to September 15th as follows:
Province of Ontario. — Cornwall and vicinity, 2; Toronto, 2;
Ottawa, 2. Province of Quebec. — St. Johns, 2 ; Farnham, 20
cases and 6 deaths since J uly 20th ; Coteau Landing, 3 ; Lon-
gueilj 1 ; Three Rivers, 2. In villages in consular district, 8.
Montreal, September 10th to lGth. — Cases reported 10th to 12th
inclusive, 132 ; authenticated by Health Department, 54. Deaths
reported from September 10th to 12th inclusive, 164. By order
of the Board of Health, information concerning reported cases is
352
MINOR PARAGRAPHS.
[N. Y. Med. Jocr.,,
dow withheld, on the ground that the information on which the
reports are based is not reliable.
The Plymouth, Pa., Epidemic of Typhoid Fever, which
it was supposed had come to an end, is reported to have again
made its appearance. One case has already proved fatal, and
several new cases have been reported.
The Health of Foreign Cities.— We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office since
the date of the last bulletin, August 29th : Montreal, Canada. —
For the week ending September 2d : 230 cases of small-pox and
96 deaths. For the week ending September 9th : 192 cases and
120 deaths. The number of cases includes only those reported
by physicians or which have been verified by the Health Depart-
ment. During the three days, September 7th to 9th inclusive,
80 cases were reported, as against 112 during the three days,
September 3d to 5th. Toronto, Canada.*— -Up to September 5th
there were only 4 cases of small-pox reported. Three Rivers,
Canada. — September 5th : One case of small-pox reported ; dis-
ease contracted in Montreal. Concord, N. H. — For the week end-
ing September 10th : The secretary of the State Board of Health
reports that there are 4 cases of small-pox in hospital at Manches-
ter, the disease being confined to the members of a French family
recently arrived from Montreal. There have been no known ex-
posures to these cases, and precautions are being taken to prevent
the spread of the disease. Havana, Cuba. — For the three weeks
ending September 10th : 92 cases of yellow fever and 29 deaths.
Cardenas, Cuba. — September 5th : Free from epidemic diseases.
Matanzas, Cuba. — September 9th : Intermittent fever prevalent.
Cape Haytien, Hayti. — In good sanitary condition. St. Thom-
as.— August 31st: 2 cases of yellow fever, in a family recently
arrived. No cases among the shipping. San Domingo. — Sep-
tember 3d : Free from epidemic diseases. Pernambuco, Brazil.
— August 7th : 1 death from yellow fever. Acapulco, Mexico. —
September 3d : Pernicious fevers prevalent. La Guayra, Vene-
zuela.— August 29th : Free from epidemic diseases. Yellow
fever in Caracas abating. Callao, Peru. — From July 18th to
August 15th : 5 cases and 4 deaths from small-pox. During the
week ending August 8th 1 case of yellow fever was reported.
Guyamas, Mexico. — August 23d : No epidemic diseases. Sani-
tary condition good. Cartagena, Colombia. — August 28th: Con-
sul reports sporadic cases of yellow fever. London, England. —
For the four weeks ending September 5th : 26 deaths from
small-pox and 12 from cholera or choleraic diarrhoea. The
number of cases of small-pox in the hospitals is 295 against 310
August 29th. Bradford, England. — For the week ending Au-
gust 22d : 1 case of small-pox reported ; the disease is also
reported as prevalent at IlHey, a neighboring health re-
sort. Paris, France. — For the two weeks ending August
29th: 11 deaths from small-pox; 29 cases treated in hospi-
tal. Bordeaux, France. — For the month of August: 4 deaths
from small-pox. Antwerp, Belgium. — For the four weeks
ending September 5th : 13 cases and 3 deaths from small-
pox. Cadiz, Spain. — For the week ending August 29: Deaths
during the week about 40 above the average. The increased
mortality is due to diarrhoea] disease and cholera. Officially,
theport is regarded clean, and clean hills of health are issued.
Gibraltar, Spain. — For the three weeks ending August 29th : 24
cases and 12 deaths from cholera. Malta, Spain. — For the two
weeks ending August 15th : Free from cholera and small-pox.
Barcelona, Spain. — From August 1st to 10th: 125 deaths from
cholera; from August 10th to 31st: 581 cases and 335 deaths
from cholera. Valencia, Spain. — For the two weeks ending
August 29th: 56 cases and 24 deaths from cholera; 5 cases and
2 deaths also occurred on a Danish vessel in the harbor, from
Barcelona. Tarragona, Spain. — For the week ending August
29th : 22 cases and 8 deaths from cholera. Genoa, Italy. — For
the two weeks ending August 30th : 6 cases of small-pox and 2
deaths. Venice, Italy. — For the two weeks ending August
22d : 8 deaths from small-pox ; diarrheeal diseases also preva-
lent. Treiste, Austria. — For the three weeks ending August
29th: 50 cases and 10 deaths from small-pox; the disease is
said to be increasing. St. Petersburg, Russia. — August 1st to
15th : 3 deaths from small-pox. Warsaw, Russia. — For the
two weeks ending August 22d : 12 deaths from small-pox. Bom-
bay, India. — For the month of July : 41 deaths from cholera.
Calcutta, India. — For the three weeks ending August 8th : 89
deaths from cholera. Hioga, Japan. — From July 1st to 25th : 4
deaths from small-pox. Osaka and Hioga, Japan. — August
8th : No cases of contagious or infectious disease reported.
During the first six months of the current year the following
cases and deaths from infectious diseases have occurred in
Japan, as reported by the Japanese Central Sanitary Bureau :
Typhoid fever, 7,984 cases and 2,078 deaths; diphtheria, 1,442
cases and 856 deaths; typhus, 444 cases and 78 deaths; small-
pox, 4,472 cases and 1,191 deaths; cholera, 16 cases and 10
deaths. The total number of cases and deaths from cholera in
Spain from March 4th to August 16th is 159,173 cases and
63,640 deaths.
The International Medical Congress.— We understand
that Dr. John C. Dalton, Dr. Thomas M. Markoe, and Dr.
Charles Stedman Bull, of New York, and Dr. Thomas F. Roch-
ester, of Buffalo, have declined to hold the positions to which
they were appointed in the organization.
Personal Items. — Dr. Fordyce Barker, after a summer
spent abroad, for the most part in sickness, returned to New
York on Saturday last. Our readers will be gratified to learn
that he is now slowly recovering and is likely soon to be in his
usual state of health.
Dr. Lewis A. Sayre, after an illness of about a year, has, we
are happy to hear, recovered sufficiently to have been able to
deliver the introductory lecture of the course at Bellevue Hos-
pital Medical College last Wednesday.
Dr. E. G. Janeway, who has been seriously ill with pneumo-
nia, is convalescing, and it is to be hoped that he will soon be
able to resume his practice.
The American Gynaecological Society.— The following
gentlemen have been elected as officers for the ensuing year :
Dr. T. A. Reamy, President; Dr. T. Parvin, First Vice-Presi-
dent ; Dr. G. J. Engelmann, Second Vice-President ; Dr. J. T.
Johnson, Secretary; Dr. M. D. Mann, Treasurer; Dr. F. P.
Foster, Dr. J. C. Reeve, Dr. B. B. Browne, and Dr. R. B. Mau-
ry, Council. The next meeting of the society will be held in
Baltimore, September 21, 22, and 23, 1886.
Buffalo General Hospital. — Miss Mary K. Howell has been
appointed superintendent of nurses, to fill the vacancy caused by
the resignation of Miss Lizzie Johnson.
College of Physicians and Surgeons of Chicago.— We
learn that Dr. J. J. M. Angear has resigned the professorship of
the Principles of Medicine.
Obituary Notes.— The death of Dr. William C. Hunter, of
New York, occurred suddenly on Saturday, the 19th inst. He
was born in Burke, N. H., in 1829, and was graduated from the
College of Physicians and Surgeons, of this city, in 1857. He
was at one time associated with the late Dr. E. R. Peaslee in
the Medical Department of Dartmouth College. He was a
member of the Medical Society of the County of New York, of
Sept. 26, 1885.]
LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES.
353
the New York Pathological Society, and of the New York
Academy of Medicine.
The death of Dr. Francis D. Cunningham, of Richmond,
Va., took place on Wednesday, the 9th inst., at the age of forty-
nine. He was born in Goochland County, Va., in 1836, and
was graduated from the Medical College of Virginia in 1857,
attending lectures subsequently at the Medical Department of
the University of the City of New York, from which be was
graduated in 1859. He was a member of the Richmond Acad-
emy of Medicine, of which he was president in 1872, and of the
Virginia State Medical Society, of which he was president in
1875. He was also a member of the American Medical and of
the American Public Health Associations, and had made a repu-
tation as an ophthalmologist.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from September 13 to September 19, 1885:
Campbell, John, Colonel and Surgeon. Retired from active
service September 16, 1885. S. O. 212, A. G. O., September
16, 1885.
Society Meetings for the Coming Week :
Monday, September 28th: Medical Society of the County of
New York; Boston Society for Medical Improvement; Law-
rence, Mass., Medical Club (private); Cambridge, Mass., So-
ciety for Medical Improvement.
Tuesday, September 29th : Boston Society of Medical Sciences
(private).
Wednesday, September 80th : Auburn City, N. Y., Medical As-
sociation ; Berkshire District, Mass., Medical Society (Pitts-
field).
Thursday, October 1st: New York Academy of Medicine; So-
ciety of Physicians of the Village of Canandaigua, N. Y. ;
Obstetrical Society of Philadelphia; Washington County,
Vt., Medical Society.
Friday, October 2d: Practitioners' Society of New York.
Saturday, October 3d : Clinical Society of the New York Post-
Graduate Medical School and Hospital ; Manhattan Medical
and Surgical Society (private); Miller's River, Mass., Medi-
cal Society.
liters to i\t Winter.
THE USELESSNESS OF ALCOHOL AND CHLOROFORM AS
LOCAL ANAESTHETICS.
26 West Forty-seventh Street, September 23, 1885.
To the Editor of the New York Medical Journal :
Sir: In the last issue of the journal I took occasion to pub-
lish some experiments showing the possibility of prolonging the
anaesthetic effects of the hydrochlorate of cocaine when sub-
cutaneously injected. I would merely add that, since the ap-
pearance of the paper in question, I have injected dilute alcohol
and chloroform beneath the skin, following the methods indi-
cated in experiments 1 and 2 [vide article in the journal for
September 19th]. The astringent coagulating effect of these
fluids, is, however, so great that they are little adapted to the
requirements of cutaneous or subcutaneous injection. More-
over, this pronounced chemical action gives rise to pain, the
severity of which appears to be in the direct ratio of the quantity
injected. I also passed a strong India-rubber ligature about the
index-finger of the left hand, and, having allowed the latter to
remain dipped in hot water until the skin was pliable, I subse-
quently immersed it in a glass containing chloroform. Although
the immersion lasted several minutes, there was little or no
anaesthesia, the prick of a pin being distinctly felt. Subse-
quently I removed the ligature, and again immersed the finger
for many minutes, but with no better results; sensibility re-
mained practically intact.
These observations tend to dissipate the expectations of
Nunnely, of Leeds, who declared that by exposure to the
vapor (!) of chloroform he had been able to cause sufficient in-
sensibility in a finger to render the performance of a surgical
operation painless. On the other hand, they confirm the opin-
ion of Simpson, who was induced, after a series of experiments,
to acknowledge that he bad little hope that by the external ap-
plication of chloroform a degree of local anaesthesia could be
induced sufficient for surgical purposes.
Cocaine, then, still remains the ideal local anaesthetic for
subcutaneous purposes when re-enforced by the good offices of
the tourniquet.
J. Leonard Corning.
ftaeebhirjs of Sonifies.
AMERICAN GYNAECOLOGICAL SOCIETY.
Tenth Annual Meeting, held at Washington, Tuesday, Wednes-
day, and Thursday, September 22, 23, and 24, 1885.
The President, Dr. William T. Howard, of Baltimore, in the
Chair.
Tuesday's Proceedings.
The Address of Welcome was delivered by Dr. Samuel C.
Busey, of Washington, who said : " Mr. President and Fellows :
I offer you the greetings of fellowship and bid you welcome as
the guests of the .Washington Obstetrical and Gynaecological
Society. Your acceptance of the invitation to hold your tenth
annual meeting in this city conferred a distinguished honor upon
our young society. On the roster of fellowship the names of
Atlee, Buckingham, Peaslee, Sims, Trask, Wallace, and White
are marked with the asterisk of death. Then, here, at the na-
tion's capital on this auspicious occasion, in the unity of a com-
mon purpose, let us join with you in that faith and devotion to
duty which have been crowned with such marvelous success and
rich rewards. You must lead, we will follow, and, when you.
have completed the labors of the present meeting, and the new
and renewed friendships are interrupted by your return to the
scenes of your daily work, if our gratitude as pupils shall be
the measure of your pleasure as instructors, your second advent
will not await the expiration of another decade."
The Natural Hygiene of Childbearing Life.— Dr. Busey,
of Washington, read a paper with this title. The hygiene of
pregnancy, he said, related to the preservation of the health of
woman during the period intervening between conception and
the commencement of labor. The processes of transformation,
development, and growth which took place were physiological,
but were, nevertheless, terminated with more or less violence
and injury to both mother and child. The unavoidable mortal-
ity was, however, small. The processes of waste and repair,
of growth and development, of organization and construction,
were next considered. There was no border-line of health.
We could not define where the physiological ended and the
pathological began. The childbearing period began with pu-
berty and ended with the expiration of tho years of maturity.
Fertility increased from the commencement of the childbearing
period until the climax was reached, and then declined to its
354
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Joub.,
extinction. The age of greatest safety of pregnancy coincided
with the age of greatest fecundity. Beyond and under, the
mortality increased with the increase and diminution of age, but
the rate was higher with the increase beyond than with the
diminution below the age of maximum safety or least mortality.
The age of nubility should correspond with the age of maximum
fecundity, maximum fertility, and least mortality. Puberty and
nubility were not simultaneous. Too early pregnancies were to
be deprecated. Nature presented the fifth quinquiniad as the
period during which the laws of fecundity, nubility, and sur-
vival found their natural complement in relatively the highest
perfection. First pregnancies were the most dangerous, and the
danger was increased by too early and too late primiparity.
The importance of lactation was next discussed. The extinction
of the childbearing function protected the remaining vital
forces from decay, but, if the seeds of disease had already been
sown, the change of life might increase their activity. If the
age of majority for women could be advanced so as to corre-
spond with tbe first year of the period of maximum fecundity,
popular prejudice and love of custom would sooner or later
conform fashion to the law. Precocious matrimony was to be
deprecated ; it was the sequel of precocious puberty. In this
country and in the higher walks of life the ratio of precocious
matrimony was on the increase — whether equally so among the
middle and lower classes, the speaker did not know. He con-
cluded by saying that the principal object of bis paper was to
direct attention to this subject and to invite discussion upon it.
Dr. J. R. Chadwick had made some investigations in re-
gard to the early appearance of menstruation in women of vari-
ous nationalities in tliis country. In over four thousand cases
he had found that American women menstruated earlier than
women of other nationalities examined. Furthermore, Ameri-
can women of American parentage began to menstruate earlier
than American women of foreign yjarentage. Scarcely enough
observations in reference to the menopause had been made to
justify absolute conclusions, but it had been found that the
menopause was appearing later in American women. The fact
that the childbearing period is increased both at the beginning
and the end would indicate added vigor.
Dr. J. P. Reynolds, of Boston, agreed entirely with the
statements made by the last speaker, and believed that tbe
women of the upper and middle classes menstruated earlier than
tbey did twenty-five years ago. He considered that this indi-
cated an activity of function which would prolong menstrual
life beyond the average period of cessation.
Puerperal Diphtheria.— Dr. Heney J. Gakkigues, of New
York, read a paper on tbis subject. This was a disease not re-
ferred to in the majority of text-books. It was one of the forms
of puerperal fever, or rather one of the different diseases in-
cluded under that term. It was distinguished by the appear-
ance of diphtheritic exudation somewhere in tbe genital tract
of the puerperal woman. It was accompanied by well-marked
general symptoms, imperiled life, and called for active treat-
ment. The paper was based upon twenty-seven cases treated
in hospital practice and two in private practice. The charac-
teristic feature of the disease was the diphtheritic infiltration,
which was usually of a light pearl-gray color, generally appear-
ing in small spots and coalescing or extending by involving new
areas. The exudation was firmly adherent to and immbedded
in the underlying tissue. It was most marked at the points
where the canal became narrow. This might be explained by
the more frequent occurrence of lacerations at those points.
The posterior wall of the vagina was more commonly attacked
than the anterior wall, which was probably due to the fact that
it was bathed with the discharges from the uterus. The exuda-
tion might, however, appear on entirely healthy portions of
mucous membrane, which had not been the seat of laceration.
The surrounding parts were more or less swollen. The connec-
tive tissue of the pelvis was infiltrated with serous fluid and
was sometimes the seat of ecchymoses. The skin was some-
times the seat of a dusky erythema, consisting of minute spots,
disappearing on pressure and not elevated. In one case pete-
chia} as large as hemp-seed existed. These were not affected by
pressure. The same patient afterward developed erysipelas.
In five cases ending fatally autopsies were made. The uterus
was much enlarged, sometimes reaching almost to the umbilicus
two weeks after labor. The cervix, having been torn, might
show diphtheritic patches or a thin gray film. In two cases
large portions of the cervix sloughed and the vagina became
gangrenous. The tissue of the uterus was friable and might be
almost difflueut. The diphtheritic exudation might affect the
Fallopian tubes. Id some cases the muscular tissue of the
uterus was scooped out as in dissecting metritis. This occurred
in four of the cases of puerperal diphtheria. In one case the
mass thrown off was four inches long, two inches wide, and one
incb thick. These masses had a pyriform shape, their outer
surface was of a gray color, and the inner surface of a flesh-
color. They were perforated with a number of holes leading
into the uterine sinuses. Under the microscope these masses
were shown to consist of smooth muscular fiber in a more or
less advanced state of fatty degeneration. The connective tis-
sue was increased. Lesions were also found in other organs
and occasionally in the joints. Difficult labors and a pre-
vious weakened condition of the patient predisposed to the
development of the condition. The real casue of the dis-
ease was, however, an infection from without. He had never
been able to convince himself that the poison passed from
one patient to the other, but it seemed to be in the air of
the ward. When a ward had been fumigated with sulphur-
ous acid there would not be a seriously sick patient for
weeks. That the poison came from without was also shown by
the fact that, when the prophylactic treatment to which he
would refer was adopted, the disease did not develop. The
first symptom which showed a deviation from a normal course
was usually the occurrence of fever, which mostly appeared
from two to four days after delivery. Sometimes there would
be a chill or chilly feelings. The temperature rose gradually as
a rule. It had ranged from 100° to 107° F., the average being
from 102° to 104°. Anorexia, vomiting, coated tongue, and
diarrhoea showed disturbance of the gastro-intestinal canal.
The patient complained of pain in tbe epigastrium and one or
both groins, sometimes extending into the legs. Examination
showed the uterus larger than it should be and quite tender-
Tenderness was often also found in the groins and some swell-
ing might also be observed. The lochial discharge was often
scanty and offensive, but in some cases it had been normal.
Where there was expulsion of the tissues of the uterus, there
had been a purulent discharge until expulsion had been accom-
plished. The diphtheritic patch commonly appeared from three
to seven days after delivery. It continued to spread for several
days, and usually stopped in from three to eight days after the
beginning of treatment. In one case the diphtheritic patches
also appeared on the tongue, indicating that the disease was
identical with the ordinary form of diphtheria attacking the
throat, The irritation of the nervous system was shown by
headache, stupor, and delirium. There was alteration of the
renal secretion and sometimes painful micturition. Three pa-
tients had albuminuria. In two cases jaundice bore testimony
to the perverted condition of the blood. The sweet breath and
profuse sweats of septicajmia were observed twice. One pa-
tient developed painful arthritis of the elbow joint. When
once the diphtheritic process was arrested, the patients recov-
Sept. 26, 1885.1
PROCEEDINGS
OF SOCIETIES.
355
ered rapidly. There was scarcely any difficulty in the diag-
nosis. When the injections of bichloride of mercury were em-
ployed they caused a yellow discoloration of abraded surfaces.
This was strictly limited to the abraded surface, and was unac-
companied with general symptoms. When the chloride of zinc
was applied to the affected surface in the treatment of the dis-
ease, a slough was caused having the color of the deposit, and
the physician was sometimes at a loss to determine whether or
not the disease was spreading. The point was decided by noting
where the application was made and by observing the edge
of the deposit. The diphtheritic deposit had a scalloped out-
line, while the outline of the slough from cauterization was
smooth. As to prognosis, five out of twenty-nine patients
died, giving a mortality of 17*2 per cent. Another might have
survived, for she lived thirty-two days and died from rupture
of the uterus, which had been thinned by sloughing, while an
assistant was giving an intra-uterine injection. The post-mor-
tem showed the walls of the uterus to be extremely thin. The
duration of the cases ending in recovery was usually about two
weeks. In cases in which a portion of the uterus was scooped
out the organ was left in a weakened condition, which in future
pregnancies might predispose it to rupture. In the way of pro-
phylaxis, it was recommended to limit the vaginal examinations
during labor as much as possible. The finger or hand should
not be introduced into the uterus unless absolutely necessary.
The delivery should be so accomplished as to avoid as much as
possible wounding of the genital canal. Instruments should be
used with the greatest care. The most important element in
the prophylaxis was the use of bichloride of mercury as an anti-
septic. Everything coming in contact with the patient should
be washed in the solution of corrosive sublimate, 1 to 2,000.
After this treatment was introduced only one case appeared in
six months, and that was due to carelessness on the part of a
resident who delivered a woman immediately after removing a
macerated foetus from another patient. After the disease ap-
peared the treatment must be energetic. The only treatment
that had given him satisfaction was that with chloride of zinc.
The affected parts were touched with a solution of equal parts
of chloride of zinc and distilled water. This was rather pain-
ful and an anaasthetic might be used. A warm solution of cor-
rosive sublimate, 1 to 2,000, was used for intra-uterine injection
where this was required, and subsequently a suppository of fif-
teen grains of iodoform was introduced. If this was done the
process need not be repeated more than once in the twenty-four
hours. The vagina was to be douched every three hours. The
parts should be examined every day, and, if the process was
not arrested, the application of chloride of zinc was to be re-
peated. If the disease was limited to the vagina and vulva, the
intra-uterine treatment was omitted. Ergot was also given
with the purpose of causing contraction of the uterus. Mor-
phine, quinine, and digitalis were used as indicated. High tem-
perature was combated with sponge-bathing, salicylic acid, and,
if necessary, the rubber coil. Carbolic acid was also given
sometimes combined with the compound tincture of iodine. If
the temperature was not very high, warm poultices were pre-
ferred. Where there was diarrhoea, warm poultices were also
considered preferable. Samples of the occlusion bandage to be
used after labor were exhibited. They consisted of a pad of
absorbent cotton wet with the corrosive-sublimate solution,
over this a piece of oiled muslin or gutta-percha tissue, and
over all another piece of absorbent cotton and a piece of mus-
lin or flannel to attach it to the binder.
Dr. W. T. Lube, of New York, had treated, ten years ago,
one hundred and fifty cases of this affection, with twenty- eight
deaths. The epidemic could be traced to a patient brought into
the hospital after a long labor. She was suffering at the time
from a syphilitic ulcer of the vulva, which was excessively in-
flamed. The child was extracted with forceps and the inflamed
perinauim was torn. Soon after this the diphtheritic deposit
appeared, and the whole ward was infected. The first cases
were the result of transference from the patient, for the ques-
tion of contagion was not then recognized as it was now. After
a time great care was taken to avoid every possible source of
contact, but the disease continued, and could be only explained
on the supposition that the air of the ward was filled with
germs. In the first cases, the treatment consisted in the appli-
cation of equal parts of solution of persulphate of iron and com-
pound tincture of iodine. The disease usually began with a cer-
tain amount of mildness and gradually became more severe. Of
the first twelve patients only two died, while in the second set
of twelve only two recovered. In the progress of the epidemic
the entire system seemed to be affected, even before the advent
of labor. Since the adoption of the use of corrosive-sublimate
injections he had not seen a case of puerperal diphtheria
Neither had he had a death from fever, nor any cases of fever*
even the old-fashioned " milk-fever " being absent.
Dr. H. P. C. Wilson, of Baltimore, was averse to the use
of bandages of any kind after delivery, preferring to have the
napkins placed under the patient so as not to obstruct the free
flow of the discharge, and to use frequent washing of the vagina
with antiseptic solutions.
Dr. W. L. Biohardson, of Boston, had treated many cases of
puerperal diphtheria with ill success, until the appearance of
Dr. Garrigues's paper. After the use of the pad and the corro-
sive-sublimate solution for the hands of the attendants and
nurses was begun, the hospital had been almost entirely free
from the disease. There had been no death since these meas.
ures were adopted.
Dr. John Byrne, of Brooklyn, asked as to the frequency of
cicatricial distortions of the vagina after diphtheria, and related
an interesting case of that sort.
Dr. Garrigues thought that the indorsement of Dr. Lusk
and Dr. Richardson would be sufficient to induce others to try
the occlusion pads. During the year preceding the introduc-
tion of the new method of treatment the mortality was nearly
seven per cent. During the next year, with the new method of
treatment, the mortality was one and a half per cent. During
the second year it was less than three fourths of one per cent.
In the institution in which these observations were made there
were many disturbing elements, one of the most important be-
ing its connection with a large general hospital. In this new
method of treatment the antiseptics were applied only to the
outside in normal cases. Only in abnormal cases were vaginal
and intra-uterine injections employed. He had only seen two
of the patients subsequent to recovery. In one there were
great shortening and narrowing, but during pregnancy softening
took place and the labor was quite easy. The second patient
was pregnant and the vagina appeared to be in good condition.
Four Cases of Oophorectomy, with Remarks.— Dr. Joseph
Taber Johnson, of Washington, read a paper with this title.
Case I.— Miss M. had suffered severely from chronic oopho-
ritis and menstrual epilepsy. She was twenty-nine years of age
and had suffered for fourteen years. There was constant pain
in both ovaries, but most of the suffering was on the left side.
For two weeks out of every month she was under the care of
an attendant, her education had been neglected, and she was in
a most deplorable condition. She had been under the care of
skillful physicians, and almost everything had been tried. Oo-
phorectomy was therefore decided upon and performed August
17, 1882. Both ovaries and one Fallopian tube were removed.
For several months she had no periods and no spasms. Gradu-
ally her menses returned and with them the convulsions in
356
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jocr.,
milder form. She was now menstruating with more regularity
than before the operation.
Case II. — Miss W., aged twenty-one, took a severe cold at
the monthly period five years before coming under observation.
Since then she had suffered from chronic oophoritis. She also
had leucorrhoea and a displaced uterus, for which she was treat-
ed without material benefit. The reader treated her for three
months without benefit and then removed the ovaries. She
made a rapid recovery and had since been free from pain.
Cask III. — Miss S., aged twenty-four, had been a great suf-
ferer from dysmenorrhoea and reflex symptoms. She suffered
with burning pain in the abdomen and head for ten days pre-
ceding menstruation. For several months there had been no
flow, but the distressing symptoms continued. Both ovaries
and tubes were removed. She made a rapid recovery and con-
tinued healthy.
Case IV. — Mrs. , aged forty, the mother of three chil-
dren, had suffered with pain in the region of the left ovary for
twenty years. She had a lacerated cervix and perinseum, which
had been restored without improving the symptoms. She had
"been under treatment for ten years, and was practically bed-
ridden for three weeks out of every month. She wished to
have the ovaries removed, but the author advised her to wait
five years longer until the menopause, which would accomplish
the same result. She, however, insisted on the operation, and
he performed it last February. She did well for three days,
when vomiting set in, and she died exhausted on the sixth day.
The speaker then referred to the great importance of an early
diagnosis in such cases in order that the operation might be
performed before numerous adhesions had taken place and be-
fore the general condition had become so depressed, referring
to the statistics of various operators in confirmation of his state-
ments. He thougbt that many patients who were now lost
from prolonged operations, on account of numerous adhesions,
might be saved if there were means by which an early diagnosis
could be made.
Dr. R. S. Stjtton, of Pittsburgh, thought that everybody
admitted that a woman with a cystic tumor of the ovary was
doomed to death if the tumor was not removed. But, when she
was suffering from some disease of the ovary which did not give
tangible evidence of its presence, the surgeon often had diffi-
culty in deciding as to the question of operation. Was the
woman to be allowed to go on suffering because evidence of dis-
ease that would justify an operation could not be obtained? It
was better to give the woman the benefit of the doubt and open
the abdomen and examine the organs. He did not think that
any one could tell the exact condition of the ovaries before
opening the abdomen. It had now come to be the practice, in
obscure conditions for which no explanation could be found and
in which it was probable that the ovaries or tubes were at fault,
to do an exploratory operation. As a rule, exploratory opera-
tions were safe. He had yet to open the first abdomen and fail
to find disease of the ovaries or tubes.
Dr. W. II. Baker, of Boston, feared tbat there was great
danger of the pendulum swinging too far and the operation
being performed too frequently. He would not discourage the
operation in properly selected cases. Greater skill was shown
in curing these patients without the removal of the organs. A
better understanding as to when the operation should be per-
formed and when not would be arrived at by studying the organ
itself very carefully in those cases in which it had been removed.
In all reports of the operation there should be an accompany-
ing report of the microscopical examination. The question of
early diagnosis had been referred to. It was a matter of the
greatest importance. The ovaries and tubes were not the easi-
est organs to examine. Even where the ovaries were adherent
to surrounding tissues it was often extremely difficult to deter-
mine this fact, and an exploratory operation might be the only
way of determining it. Where an exploratory incision had been
made, and the organs found healthy so far as their gross appear-
ance was concerned, he insisted that they should be put back
and the abdomen closed, even if the woman suffered excruciat-
ing pain with menstruation.
Dr. T. A. Emmet, of New York, said that he was not an
advocate of the operation, and he thought that more harm than
good had been done by its performance. There were cases
where it must be done. Where there was salpingitis with the
tubes filled with pus, the operation was certainly indicated.
That it should be done, as it frequently was, for the relief of so
many symptoms was a reproach on the profession. He did not
advocate the opening of the abdomen for the purpose of mak-
ing a diagnosis. If the diagnosis could not be made before
hand, he did not think it justifiable to run the risk of opening
the abdomen. For three years he had been looking for cases
in which he considered the operation indicated, and had seen
but two such cases. . One was a typical case in which there had
been several attacks of peritonitis following gonorrhoea. Both
tubes were as large as the wrist, and the history indicated the
existence of pus. An operation was urged, but the patient re-
fused. For five months there was no improvement. The treat-
ment consisted of hot-water injections, keeping the bowels
regular, daily applications of iodine, and attention to the gen-
eral health. After several months the tubes began to diminish
in size, and in the course of a year the accumulation had en-
tirely disappeared and she left the hospital apparently a well
woman. The second case was similar. That patient also re-
fused an operation. She was now no worse, and in some re-
spects better, than she was some years ago.
Dr. Lusk thought great caution must be exercised in the per-
formance of this operation. He did not condemn it, and had
himself operated in four cases in which there was distinct evi-
dence of disease of the tube, with good success.
Dr. E. W. Jenks, of Detroit, had seen several cases in which
the operation had been performed without benefit. Where the
ovaries and tubes were diseased there could be no question as
to the propriety of its performance. In many of these cases of
so-called hystero-epilepsy, which were often nothing more than
hysteria, he considered the removal of the ovaries a positive
wrong. The exploratory operation was not free from danger.
Dr. T. A. Reamy, of Cincinnati, said that a woman had been
sent to him with dysmenorrhoea and hysterical symptoms, with
the request that he should remove the ovaries. Five months'
treatment of the cavity of the uterus, with change in the pa-
tient's surroundings and general treatment, resulted in entire
recovery. He had seen several other striking cases. It was
the exception to find the ovary healthy in women after the age
of forty.
Dr. Emmet thought that the operation should never be done
for dysmenorrhoea. He considered dysmenorrhoea a neuralgic
condition, the result of anaemia. When dysmenorrhoea was re-
lieved by the operation, it was because the general nutrition
was improved by the removal of the ovaries.
Dr. Sutton agreed with Dr. Baker that where, in an explora-
tory operation, the ovaries and tubes were found to be healthy,
they should not be removed.
Dr. Mann said that, although, as Dr. Emmet had stated, dys-
menorrhoea was a neuralgic condition, he thought that that con-
dition might become so firmly established that it could not be
relieved without taking out the organ affected with the neural-
gia. In two such cases he had thought the operation indicated.
In one the patient was free from pain only three days of each
month. He advised the operation, which was performed by Dr.
Sept. 26, 1885.]
PROCEEDINGS OF SOCIETIES.
357
Olark, of Niagara Falls. The patient completely recovered. The
second case was his own. The woman had suffered for a num-
ber of years with excruciating pain. The ovaries were enlarged
and tender. The whole abdomen was tender. The ovaries were
removed and the patient entirely recovered her health. He
could not admit that there were no cases of ovarian dysmenor-
rhcea which could be relieved by the operation, but they were
rare.
Dr. JonNsoN had not recommended the operation except
under well-marked indications. He agreed with those who
feared that the operation might be performed oftener than
necessary. Its use in nervous and neuralgic conditions was not
always so beneficial as in some other conditions, such as myoma
of the uterus, for example.
(To be concluded.)
BROOKLYN PATHOLOGICAL SOCIETY.
Meeting of March 12, 1885.
The President, Dr. B. F. Westbrook, in the Chair ;
Dr. A. H. P. Leuf, Secretary.
On the Use of Cocaine in Minor Surgery— This was the
title of a paper read by Dr. H. T. Halleck. [See page 343.]
Dr. Arthur Mathewson remarked that it was in the room
in which the meeting was held (in the Brooklyn Eye and Ear
Hospital) that the first use of cocaine as an anaesthetic in the
United States had been made. Dr. Noyes saw it for the first
time in Germany, at the Heidelberg Congress; he also saw it
privately demonstrated. The speaker had had Dr. Squibb make
him a two-per-cent. solution of Merck's preparation, and it had
proved very satisfactory — in fact, quite as effective as a four-
per-cent. solution. The drug now prepared by Dr. Squibb was
unexcelled. Some preparations caused a great deal of irritation
at first, but this soon disappeared. The boric-acid preparation
sent him by Dr. Squibb was the least irritating. Micrococci and
bacilli formed in it, however, and it was almost impossible to
prevent their formation. There was a difference in patients
concerning the usefulness of this remedy — with some it did
well, while with others it did not. As to its effect upon the
lids, he referred to a case of cut lids that had been soaked with
the solution previous to the operation, and the patient was any-
thing but loud in its praise. It was usual to meet with failure
in that class of cases. When he removed a cyst of the lid he
cut from within (on the conjunctival side), pressed out the con-
tents, and stirred up the interior with a small curette. The
effect of cocaine on children operated upon for strabismus was
quite striking; they were so very quiet.
Dr. R. G. Eooles was reminded of hypnotism by some of
the experiments with cocaine. A few years ago an American
physician had made the same preparation, and called it ery-
throxyline hydrochloride. He left a specimen at the college
with his thesis. The speaker had found cocaine satisfactory in
parturition.
Dr. W. C. Burke, Jr., had been told by Dr. Polk that he
had been using it in a series of labor cases during the first stage.
He injected it deep into the cervix and the surrounding connec-
tive tissue, with the result of causing a loss of sensibility in all
the parts below the umbilicus, although pains in the back and
the epigastrium persisted. The effect lasted from half to three
quarters of an hour. It had no ill effect, and it did not influ-
ence dilatation. The speaker had used it before incising a pin-
hole os, previous to dilatation of the cervix, which was accom-
plished with very little pain, the patient only experiencing a
*' pulling feeling." He had employed the American product,
and had found it irritate the eye for several minutes.
Dr. C. N. D. Jones thought it as important to report failures
as successes in the use of new drugs. The medical journals con-
tained very few reports of failures, but failures could be grouped
and studied to advantage. He had used the drug wherever it
was applicable. He had found it useful in laryngoscopy. In
enucleation of the tonsil there was some pain, also at times in
manipulations involving the urethra.
Dr. G. W. Brush had tried a fifteen-per-cent. solution, but
with very little effect. His experience had been with Merck's
and McKesson & Robbins's preparations.
Dr. Leuf said that the unsatisfactory results mentioned in
the two cases reported by Dr. Halleck might be accounted for
by the preparation used having been of inferior quality. He
had subsequently employed it in two prepuce operations in chil-
dren, and also in several eye cases, with satisfactory results.
The drug acted decidedly as a hemostatic, at least on small sur-
faces. In all recent cases he had used Merck's cocaine.
Epithelioma of the Eyelid removed by Applications of
Benzol. — Dr. Mathewson reported the following history of a
case : An Irish laborer, fifty years old, was first seen October
31, 1883, when he had a growth on the right lower lid, project-
ing two thirds of an inch, with an ulcerated surface. It had
first been noticed, as a warty excrescence, a year or two before,
and it had lately begun to grow rapidly. Microscopical exami-
nation, by Dr. W. H. Bates, showed it to be clearly an epithe-
lioma. At first the treatment consisted in dusting the granu-
lating surface with calomel ; afterward (at the suggestion of Dr.
Bates, who had records of two cases of epithelioma treated
successfully, in his own practice, with the agent) in applications
of benzol. After about three months' use of these remedies,
applied three or four times a week, the growth had completely
disappeared, leaving a smooth, depressed cicatrix. On the 1st
of March, 1885, the man came back, with the history of a small
ulcerating spot having appeared some six months before at the
outer edge of the cicatrix. This was extending rapidly, but
quickly began to contract under renewed applications of the
same remedies, and was much reduced in size when the patient
was presented at the April meeting of the New York Ophthal-
mol ogical Society. On the 1st of May, when the patient left
town, it was scarcely noticeable. On the 8th of July the man
appeared again, with a considerable increase in the size of the
ulcerating surface, but it had again yielded promptly to the ap-
plications. The benzol was brushed over the ulceration and
the adjacent surface after they had been carefully wiped, and
calomel was then dusted on. The applications were made from
two to four times a week.
A case of necrosis of the tibia was presented by the Presi-
dent, and specimens of cystic kidney, calculous impaction of
the bile-ducts, and renal calculus were shown by Dr. H. D.
Bliss, and the histories of the cases related.
Meeting of March 26, 1885.
Acute Dysentery— Dr. C. N. D. Jones showed a portion
of the intestine of a lad, fourteen years old, who had died of
acute dysentery occurring while he was under treatment for a
fracture of the neck of the os brachii and a comminuted frac-
ture of the shaft of the os femoris. The injury was received on
the 7th of July, 1884, by his falling to the ground from a roof
on which he was at work, and he was taken to the Brooklyn
City Hospital. He did well until the 1st of August, when he
complained of griping pains in the abdomen. There was tender-
ness on pressure, especially in the left iliac fossa. The next day
diarrhoea came on, and soon passed into dysentery. Death took
place on the 19th of August.
At the autopsy it was found that the fracture of the thigh
had not united. The small intestine was somewhat congested,
358
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. JouK.y
but otherwise normal. The transverse and descending colon
were contracted, and the entire colon and the rectum were
thickened. Their mucous membrane was extensively ulcerated,
the ulcers being largest and most numerous at the lower part.
Instead of the intestinal tube being examined in the usual man-
ner, by slitting it longitudinally with an enterotome, the colon
was separated from the ileum, and a portion of the severed end
was then rolled outward, and, a part of the gut being invagi-
nated, a forcible stream of water was thrown into the sulcus
thus formed on the peritoneal surface, with the result of rapidly
producing complete inversion of the tube. The intestine was
then inflated with air, and preserved in that condition.
Acute Rheumatism complicated with Suppurative Ne-
phritis.— Dr. Isaac H. Platt read the notes of the case of an
Irish servant girl, twenty-seven years old, who had been treated
at St. Mary's Hospital, in the service of Dr. Kuhn. When she
was admitted, on February 19th, she presented the typical
symptoms of acute rheumatism, which followed the usual course
for a period of nine days. On the 26th the temperature, which
had been ranging from 103° to 105-5° F., fell to 102-5° in an
hour under the influence of forty grains of antipyrine. The
drug was then given in doses of thirty grains every four hours;
the next afternoon the temperature had fallen to 101°, and the
girl seemed better. The next day, however (the 28th), the tem-
perature rose again to 104° despite the continued use of the
drug, and in the evening she became actively delirious. The
next day she passed into a typhoid condition, with low mutter-
ing delirium, subsultus tendinum, and carphologia. Careful ex-
amination was made for thoracic and abdominal complications,
but none were found. The urine had been examined a few
days before, and found free from albumin and sediment. Stimu-
lating treatment was pushed to the utmost, but she gradually
sank, the delirium persisting to the last, and died on the 3d of
March. For two days before that time there had been no joint
symptoms.
Report of the Autopsy, by Dr. Leuf. — Rigor mortis moder-
ate, thirty-one hours after death. Lungs normal, except for
collapsed portions in the right lower lobe, and less marked in
the left lower lobe, together with several very hard pigmentary
nodules of the size of a millet-seed. The heart was pale, soft,
and flaccid, with all its cavities containing blood, mostly fluid,
the little that was clotted being soft and friable. The liver was
dark, and of normal consistence and vascularity. The pancreas
was pale and soft. The left kidney wyas pale and soft, but
otherwise normal. So was the right one, except in its upper
third, which was dirty-yellow and rough externally. Thin, ill-
conditioned pus and debris exuded from the cut renal pelvis.
An abscess was found in the upper part of the organ, involving
exactly the superior pyramid — no more and no less. The apex
of the pyramid next below was also full of cheesy material that
was breaking down and had a marked tubercular appearance.
The uterus was congested, anteflexed, retroverted, and deflected
to the right by the rectum, which was distended with gas. The
endometrium was congested and exfoliating. The right ovary
contained an old corpus luteum, about six mm. in diameter. Mi-
croscopical examination, by Dr. J. H. Hunt, showed numerous
minute abscesses, but no tubercles.
Dr. Josephine A. Dupre had had some experience with
rheumatism produced, in rabbits and dogs, by intra-peritoneal
injections of lactic acid (two per cent.). One case resulted in
endocarditis; two others in acute articular rheumatism; and
four others in additional acute suppurations — in one case acute
suppurative nephritis, in another several abscesses of the ab-
dominal wall, in the third a pelvic abscess, and in the fourth an
abscess of which she had forgotten the situation. The clinical
histories of these cases were typical of acute inflammatory rheu-
matism, and the suppurative processes were demonstrated by
post-mortem examination.
Cerebro-spinal Meningitis in a Roller-Skater. — Dr.
Geokge W. Gushing said that, about midnight of March 11, 1885,
he had been called to see the patient (J. C), who was twenty-
eight years old and of fine muscular development. He was-
restless, with a hot, dry skin, the pulse 135, the temperature
104° F., the respiration labored, headache, and the pupils con-
tracted and intolerant of light. He also had marked pharyn-
gitis and bronchial congestion. He was averse to talking and
to being disturbed. A febrifuge mixture was ordered, also
bromide of potassium. Subsequently the man's wife gave the
following history: Her husband had been engaged in a roller-
skating match at the Madison Square Garden the week before,
ending at midnight March 7th. He was at home the next day
(Sunday), and rested a part of the time, but was unable to eat,
and seemed very much exhausted. He went to New York on
Monday, for the purpose of getting the money due him from
the proceeds of the contest, and did not return until Tuesday,
when he had symptoms of an ordinary "cold." The patient's
surroundings were so poor that it was impracticable for all the
speaker's directions to be carried out, and, when he called the
next morning, ho found that stupor was gradually setting in.
There were urinary incontinence and spontaneous bloody evacu-
ations from the bowels; there was also great difficulty in taking
food and medicines, and the head was rigidly drawn back. The
ankles and feet were swollen and chafed from the pressure of
the skates. Cerebro-spinal meningitis was diagnosticated, and
counter-irritants were applied to the spine and the back of the
head, with cold to the top of- the head. He continued to grow
worse until the 15th, when the speaker was called in haste, and
found him dead — he had probably been dead for several hours.
The autopsy confirmed the diagnosis, the case having been
placed in the Coroner's hands as a matter of public interest in
connection with the present furor in regard to roller-skating.
Report of the Autopsy, by Dr. Leuf. — " The thoracic, ab-
dominal, and cranial contents were examined by Dr. A. War-
ner Shepard, while it fell to my lot to" examine and take notes
of the spinal canal and cord. The body was of average height
and build. The muscles of the lower extremities were rather
well developed. There was very little fat. The left great
toe was blistered interiorly, internally, and superiorly, but the
nail was not affected. The lungs were hypostatically con-
gested behind and at the bases. The right lower lobe was col-
lapsed at its anterior margin and posteriorly at the base. The
heart was normal, except the usual eccentric hypertrophy found
in athletes. The stomach was empty and tubular. The liver
was normal, with the exception of some occasional fatty infil-
trations. The spleen was a little larger than usual. The kid-
neys were healthy, but large ; the right one was darker than
the left. The bladder was so distended as to half fill the pelvis.
The portal vein and its tributaries were distended with blood.
The dura mater of the brain and cord presented nothing abnor-
mal. The pia mater, however, was yellow, and about 3 mm.
thick over the anterior half of the cerebral convexity on either
side. All over this area the convolutions, including the upper
two temporo-sphenoidal convolutions, were hidden from sight;
but over the posterior half of the convexity the convolutions
were distinctly discernible, and only the sulci were filled with
pus. The inferior, or orbital, surfaces of the frontal lobes were
deeply injected, but not purulent. The yellow thickening of
the pia was also noticeable in the anterior half of the great me-
dian fissure of the brain, and extended half-way down to the
corpus callosum. This purulent condition of the pia extended
to the base of the brain, along the Sylvian fissure, to the inter-
peduncular space, where the same suppurative condition of the
Sept. 26, 1885.]
PROCEEDINGS OF SOCIETIES.
359
pia was noticeable. That covering the pons and surrounding
the medulla was affected in like manner. The intra-meningeal
space of the cord was filled with pus to such an extent as to
distend the dura, and well up in the incision made into the mem-
brane in the lower part of the vertebral canal, preparatory to
extracting the cord. The pia, throughout the whole length of
the cord, was thick and yellow, while the cord itself was soft-
ened throughout its whole extent below the cervical enlarge-
ment. It was also sclerosed on the left side in the upper tho-
racic region, the white portion being principally affected."
In regard to the aatiology of the case, Dr. Leuf would differ
with those gentlemen who would attribute the man's death to
a healthful and beneficial exercise. That the prolonged mental
and physical strain to which he had necessarily been subjected,
together with the known privation and exposure, were impor-
tant factors in bringing about the termination of the disease, no
one could or would deny ; yet it was wrong, he thought, to
consider them the causes of the trouble. When we reflected
how little there was in the way of precedent for such a suppo-
sition, in the face of extremely prolonged and excessive walk-
ing, running, rowing, swimming, and the like, it was fairer and
more rational to infer that this meningeal inflammation had
been brought about by a pre-existing cause. Still, the case
might accomplish much good by checking the rage for roller-
skating, although it was desirable that as many persons as pos-
sible should avail themselves of this graceful and harmless ex-
ercise within proper limits. Probably it should not be indulged
in much more than half an hour at any one time. It was in-
teresting to inquire how much work the craze was likely to
bring to gynaecologists and to specialists in diseases of the chest,
and perhaps to neurologists.
Meeting of April 9, 1885.
Exsection of the Upper Third of the Tibia.— Dr. George
"Wackerhagen read the notes of the case of a child, two years
and a half old, who fell upon the pavement in May, 1884, and
bruised the left knee. At first the injury seemed to be trifling,
but a month later the part gradually became painful, red, and
swollen. The services of a surgeon were not obtained until the
25th of September, when an opening was made just below the
knee joint, which gave exit to a quantity of dark-colored blood
slightly mixed with pus. After that the swelling disappeared,
leaving a little opening just below the spine of the tibia, from
which a small quantity of unhealthy pus was discharged daily.
The speaker saw the child in consultation on the 15th of Octo-
ber, and found two sinuses leading to dead bone. At the opera-
tion, on the 19th, it was found advisable to remove the whole
head of the tibia, together with about one third of the shaft,
by subperiosteal exsection. The crucial ligaments were found to
have been entirely destroyed, and the inter-condylar space was
filled with unhealthy granulations. These were removed with
a sharp curette, and the joint was thoroughly irrigated with a
l-to-2,000 solution of bichloride of mercury. A rubber drain-
age-tube was introduced into the joint, and the wound was
packed with iodoform and bichloride gauze. No inflammatory
reaction followed, and the temperature did not go above 99° F.
The child had improved very much since the operation, and
new bone had been produced from the periosteum. The knee
could be flexed to an angle of about 45°, and extended as in the
normal condition. Bauer's hip-joint instrument had been ap-
plied for the purpose of making continuous extension, and the
shortening was not more than half an inch.
Gangrene of the Lower Extremity from Arterial Throm-
bosis.— Dr. F. A. Jewett reported the case of a student, seven-
teen years of age, previously of good health, who had consulted
him on the 30th of January, suffering apparently with a slight
attack of intermittent fever. Several weeks before, he had in-
dulged excessively in skating. Under the influence of quinine,
he was soon able to be about the house. On the 4th of Febru-
ary, in the afternoon, he complained of pain in the back, but
this had disappeared by the next morning, when, while dress-
ing, he suddenly felt a numbness in both lower limbs, together
with a "peculiar sensation " in the abdomen. He rapidly grew
worse, so as to lose the powers of motion and sensation. By
means of friction and a hot mustard bath sensation was restored
to both extremities, but was soon lost again in the left leg. The
speaker now arrived, and found the left leg blanched and cold
below the knee, with loss of motion and sensation. There was
little pain. The patient was placed in bed, and the limb was
surrounded with hot bottles. The next morning there were
ecchymotic spots on the lower third of the thigh and the leg
and foot. On the 7th burning pains appeared in the knee and
foot, and the temperature was 10ii-5o F. On the 6th of March,
the line of demarkation having fully formed at the middle of the
thigh, circular amputation was performed in the upper third,
the incision coming within an inch of the healthy granulations.
The femoral artery was found to be completely plugged, and the
slight haemorrhage which resulted came entirely from the
smaller vessels. The patient died of shock two hours after the
completion of the operation. In disguising the odor of the gan-
grenous parts, at the time of the operation, the best result was
obtained with nascent chloride of lead, made by adding a drachm
of aqueous solution of nitrate of lead to a pailful of solution of
salt.
Autopsy, by Dr. Leuf. — The kidney connective tissue was
markedly increased. The spleen was enlarged, and contained
buff-colored spots. The liver was slightly fatty. A clot was
found in the abdominal aorta, about four cm. above its bifurca-
tion and extending down into the two common iliacs. It only
partly filled the aorta and the right common, external, and in-
ternal iliacs, so that some blood had been admitted through
these vessels to the parts below ; but the left common, external,
and internal iliacs were solidly and perfectly plugged with a
firm thrombus adherent to their walls. This plug extended
down into the femoral as far as the end of the stump, where it
had been cut off during the operation. The plug fitted the
vessel somewhat loosely below the lower part of the external
iliac. The collateral circulation probably took place through
the deep circumflex iliac and the lumbar arteries.
Gangrene of the Leg due to Popliteal Embolism.— Dr.
Leuf related the case of a German midwife, about thirty-five years
old, who had had rheumatism at times for fourteen years, also fre-
quent attacks of dyspnoea due to cardiac valvular disease. The at-
tack of rheumatism which terminated her life began in the latter
part of April, and at that time she was attended by another
physician. She had the ordinary symptoms of rheumatism, and
presented inflammatory signs in both ankles. After some days'
treatment the feet became better, and the physician had a pack
of ice-water and salt applied to the left foot. This was con-
tinued under protest for upward of two hours and then re-
moved. A few hours later the patient felt a sensation as of
something darting down the left thigh, along the course of the
femoral, and stopping with a sudden jar at the back of the knee.
This sudden jar was a shock to her whole body, and caused the
entire leg below the knee to feel as if suddenly electrified, and
the leg had continued numb, with tingling sensations, from that
time until the speaker was called in, two days later. The other
physician could not be induced to pay any attention to these
symptoms, or even look at the foot. The speaker found the
foot cold and swollen, with the plantar surface of a dark hue.
The sensibility of the foot was impaired, and it could hardly be
moved. The patient complained of severe pains in the toes and
360
MISCELLANY.
[N. Y. Mku. Join.,
instep. Her pulse was very irregular and lier heart feeble,
with mitral stenotic and regurgitant murmurs well marked.
Her face wore an anxious, expectant expression, and was of a
leaden pallor. She had black hair and a dark complexion.
Examination at the back of the knee revealed a rod-like body
beneath the skin in the popliteal space, having a diameter of
-over 1 cm. This hardness extended almost the whole length of
the popliteal space. The diagnosis was made at once of embo-
lism of the popliteal artery, from the lodgment of a detached
heart thrombus caused by valvular disease the result of acute
inflammatory rheumatism. The treatment consisted in giving
opium and Cannabis indica to relieve pain and mental depres-
sion; digitalis to strengthen the heart; Cascara sagrada and
extract of malt to relieve constipation and promote a flagging
appetite; wine to hasten reaction; and a good nutritious diet
to maintain and increase her strength. The speaker's prognosis
was gloomy, and he predicted gangrene of the left foot and leg.
Tie considered it dangerous to operate, because of the patient's
condition and the irregular action of her heart, and believed she
had the best chances of recovery by patiently awaiting sponta-
neous amputation. Hot applications were made to the foot and
leg. Her general health continued good, and she ate abundant-
ly. The pain grew very much worse, so that she was not freed
from it even by taking a grain of opium every hour almost con-
tinuously for days. The foot became darker, and the toes black
and dry. Dark-red patches made their appearance about the
ankle, and gradually extended up the leg almost to the knee,
from which point they receded about 4 cm. and began to form
a line of demarkation. This line was dentate, so as to form two
side flaps if spontaneous amputation occurred. Dr. B. F. West-
brook was called in consultation by the speaker, and fully coin-
cided with him in regard to the case. A few blebs formed on
the foot and ankle, and afterward on the leg, exuding a semi-
gelatinous, sero-sanguineous fluid. The stench was considera-
ble, but it was easily controlled with carbolic acid and bichlo-
ride-of-mercury solution. On the 29th (twenty-four days from
the time he first saw her) the speaker found the patient sitting
up, panting for air, with all the signs of orthopncea. Mucous
rales could be distinctly heard without applying the ear to the
•chest. After consultation, and taking her preceding history
into consideration, he concluded that she had a pulmonary in-
farction and oedema of the lungs. It was Sunday, so that no
■oxygen could be obtained; and large doses of chloride of am-
monium were prescribed. The next day she was found in a
dying condition. An autopsy was not allowed.
There had seemed every reason to believe that, had it not
been for the unforeseen accident, her strength would be suf-
ficient to carry her through the process of spontaneous amputa-
tion. Her heart's action was so irregular and incompetent that
she would have been very likely to succumb to an anaesthetic.
Taking into consideration the general results of cases of gan-
grene, we learned that the majority of the patients operated
upon died, and death was often hastened by the shock of the
procedure. It seemed to the speaker that a large proportion of
patients would fare better with nature than with the surgeon ;
nevertheless, the reverse was true of many others. He felt cer-
tain, therefore, that, by a more careful selection of cases with
reference to the advisability of operating, a much larger per-
centage of recoveries would result.
The two cases of gangrene being under discussion, Dr. Leuf
remarked that, after careful consideration, he was disposed to
ascribe a spinal origin to the thrombus in the first case, on the
supposition that a special myelitis might set up nutritive changes
in the coats of the aorta, and these in turn give rise to the
thrombus. Ho thought this the best way to account for the
formation of the plug. The excessive exercise of both lower
extremities might he sufficient cause for the inflammation of the
cord.
Dr. C. N. D. Jones thought the fever symptoms would have
been interesting as bearing upon the question of whether the
primary cause was a myelitis or an arteritis. He wished to
know if there had been any syphilis.
Dr. Jewett replied that the case began with chills and fever
on a Wednesday; there were no chills the day before, but there
had been some on the preceding Monday, ne did not see the
patient on Thursday, but saw him afterward, when he was
without fever. No syphilitic history could be obtained; if
there was any syphilis, it must have been hereditary. The pa-
tient only complained of numbness of the left thigh. In Simp-
son's works mention was made of an obstetrical case almost
parallel. The plug was about 2 5 cm. above the bifurcation,
and the symptoms were about the same. The connection be-
tween the cord and the thrombosis that had been suggested
was not very clear to him, and seemed a little strained. He
also thought it questionable if excessive exercise was the cause
of the trouble.
Dr. Leuf rejoined that the lack of much pain in Dr. Jewett's
case would support the myelitis theory.
The President thought it rather curious that sclerosis and
softening should have taken place, as it would appear in this
case, with hardly any symptoms. He asked if the patient had
been skating shortly before the onset of the sickness.
Dr. Jewett answered, " A few days before."
The President added that it was also curious to see inter-
stitial nephritis in one so young. This kidney trouble and cord
affection were sometimes associated. Perhaps this case was
one of embolism, and not of thrombosis.
Dr. Jewett said that there was no post-mortem evidence of
any possibility of embolism.
The President asked if the plug, extending so far down as
it did, would not prevent the collateral circulation suggested by
Dr. Leuf.
Dr. Leuf explained that the plug fitted the vessels loosely
from a point in the external iliac about 2 cm. above the ilio-
pubic ligament.
The President, in reply to a question as to the advisability
of an operation in Dr. Leuf's case, said that it was absolutely
contra-indicated by the gross incompetence of the heart.
The International Medical Congress. — The "Maryland Medical
Journal " comments as follows on the recent work of the American
Medical Association's new committee:
" We present in another column a partial report of the new com-
mittee on the Congress, which held its meeting in New York city on
September 3d. We invite attention to the recent work of this com-
mittee, and would urge our readers to compare this work with that of
the first Committee on the Organization of the Ninth International
Medical Congress, which was published in the number of this Journal
of April 4, 1885. We will attempt, in a brief way, to show by way of
comparison that the new committee has played its part in this affair in
a manner in thorough accord with what might have been expected of
it. This committee should never have had an existence in the first
place. It has failed to do anything save provoke strife and differences
in the profession in this country, and this last attempt to organize the
preliminary arrangements for the Congress is but the crowning act of
its incapacity and unfitness for the work it has undertaken. The com-
mittee was called into existence by a small faction of sore-heads at New
Orleans, which introduced false and absurd issues into the plan of or-
Sept. 26, 1885.]
MISCELLANY.
361
ganization of the Congress, with no purpose of promoting the welfare
and scientific work of the Congress, but simply to make prominent
certain private grievances and petit ambitions. The agitators of this
rebellious movement against the work of the first committee were
chiefly men who failed to receive appointments in the organization of
the Congress.
" In order to overthrow the work of the first committee the cry of
the ' code ' was raised, and sectional feelings were appealed to. The
work of disorganization was in this wise inaugurated. We ask every
impartial mind, What does this mean ? In what way have the fortunes
of the Congress been benefited by the work of the new committee ?
Will any one venture to assert that the Congress can be a success under
the arrangement now proposed ? We will endeavor to answer these
propositions.
" First, we will call attention to the fact that the new committee has
virtually thrown aside the 'code' issue. It has thrown open the doors
of the Congress to all members of the regular profession of medicine in
this and other countries, with no restrictions other than the simple in-
scription of their names on the register, and taking out of tickets of
admission. The committee does not undertake to say who are mem-
bers of the regular profession. This plan is the one proposed by the
first committee, but not the one proposed by the new committee at the
Chicago meeting, which forced a large number of the first appointees
to present their resignations. In short, this new committee has ac-
cepted the work of the first committee after having driven out of the
organization of the Congress a large number of the most distinguished
members of the profession in this country. By introducing the absurd
'code' issue at Chicago, the committee has completely alienated from
the organization of the Congress the very best scientific minds. It has
rescinded its destructive work at Chicago in the face of the adverse
criticism of the almost entire medical press in this country and in
Europe, but not until after it had succeeded in filling a number of its
appointments with men of second-rate merit. The committee adopts
the ' code ' issue in this respect only. It has made no appointments
except with ' old-code ' adherents. The present organization, there-
fore, will only be represented by ' old-code ' men. In order to carry out
the ' code ' idea and the ' sectional ' idea, the committee has filled the
various offices of the Congress with men, a few of whom are scarcely
known at home or abroad, and whose fitness for the positions to which
they have been called may be regarded as of questionable character.
" Second, we direct attention to the fact that the rules for the gov-
ernment of the Congress are almost identical with those framed by the
first committee. The first committee created nineteen sections, whereas
the present arrangement provides for only seventeen ; but this change
has been brought about in this manner. The Section on Medical Edu-
cation, Legislation, etc., has been dropped and the Section on Otology
has been added to the Section on Laryngology. A number of verbal
alterations were introduced into the rules adopted by the new commit-
tee, but the general purport of these rules is the same as adopted by
the first committee.
" The only reformation made by the committee in the plan and
organization adopted by the first committee is reduced to this:
4 new-code ' men have been dropped and ' old-code ' men have been
substituted for them. The changes in the personnel of the presi-
dents of sections are thus shown. In the Section on Anatomy, W.
H. Pancoast, of Philadelphia, has been substituted for Joseph Leidy,
of Philadelphia ; Section on General Surgery, William T. Briggs,
of Nashville, for D. W. Yandell, of Louisville ; Section on Medicine,
A. B. Arnold, of Baltimore, for J. M. Da Costa, of Philadelphia ;
Section on Obstetrics, DeLaskie Miller (residence not known to us) for
T. A. Reamy, of Cincinnati ; Section on Therapeutics, etc., F. H. Tirrell
(residence not known to us) for H. C. Wood, of Philadelphia ; Section
on Military and Naval Surgery, Henry F. Smith for David L. Hunting-
ton, U. S. A. ; Section on Pathology, E. 0. Shakespeare, of Philadel-
phia, for Francis Delafield, of New York ; Section on Diseases of Chil-
dren, J. Lewis Smith, of New York city, for Abraham Jacobi, of New
York ; Section on Ophthalmology, J. W. Calhoun (residence not known
to us) for Henry D. Noyes, of New York city ; Section on Otology and
Laryngology, S. J. Jones, of Chicago, for Clarence J. Blake, of Boston,
on Otology, and George M. Lefferts, of New York city, on Laryngology ;
Section on Dermatology and Syphilis, A. R. Robinson, of New York city,
for William A. Hardaway, of St. Louis ; Section on Public and Inter-
national Hygiene, Joseph Jones, of New Orleans, for Hosmer A. John-
son, of Chicago ; Section on Collective Investigation, etc., Henry 0.
Marcy, of Boston, for N. S. Davis, of Chicago ; Section on Psychological
Medicine, John P. Gray, of Utica, N. Y., for S. Weir Mitchell, of Phila-
delphia.
" It will thus be observed that the changes made by the committee
in the appointees of the Congress are not of a character to inspire the
very highest order of scientific work, nor do we believe that the Congress
as now organized will attract that attention and interest it would have
received under the plan of organization first proposed. The revolu-
tionary work of the American Medical Association, in authorizing the
changes made by its committee, is entitled to every atom of criticism
and censure it has received. There was no reason or justice in its
action. This action will have but one result, that of lowering the
standard of scientific work in this country and of introducing into the
ranks of the profession an element of discord and disturbance which can
not be effaced during the next generation. The association has given
its entire influence toward elevating the claims of men who care more
for their own advancement than for the general professional good. It
has favored an alliance with ideas and principles which have no exist-
ence in the scientific creed of our times. The present organization of
the Congress, as far as it is known, bears no comparison in point of
ability and authority to the first organization. Inasmuch as it has been
called into existence out of deference to false issues and demagogical
ideas, its results will not only prove highly prejudicial to the success of
the Congress, but can have only an unfavorable influence upon the
status of the profession in the United States."
The "Medical Record" says:
" For the first time in its history the International Medical Congress
has fallen into the sole management of a society of the country in
which it is to meet. Although Sir James Paget, an ex-president, ex-
pressly affirms that this was not expected or desired when an invitation
was given, yet it is evident from recent events that the society referred
to intends to retain its 'iold and force upon the Congress its own men
and methods. The wo^ of the committee which met here in such se-
crecy on September 3d but too surely confirms this. Details of its
mysterious labors are given elsewhere. These show some indications
of adroit wriggling to escape the results of previous blunders, but no
manly meeting of the issues, and no recognition of the real demands of
the profession. The committee have utterly eliminated and blotted out
Drs. Cole and Shoemaker, trusting, we presume, to gain back Philadel-
phia by thus making scapegoats of these gentlemen. They have also
filled the vacancies in the presidencies of the sections. Their list of
names suggests both freshness and decay, but does not fairly represent
American medicine. And the profession will very quickly ask who
many of these new men are who thus take the seats which have here-
tofore been held only by recognized leaders. Is our country to be made
ridiculous by their upheaval, and the Congress turned into a menagerie
of unknown doctors and ethical sticklers ?
"However, though the appointments are weak enough, they need
not kill the Congress. But a much more serious thing remains : no
attempt was made to remove the code issue from the Congress. It is
still incumbent on an American physician to subscribe to the American
Medical Association's Code of Ethics in order to hold any official posi-
tion in the Ninth International Congress — if it meets in this country.
The stupidity, as well as absolute wrongfulness, of failing to meet this
point is certainly beyond parallel. The good Lord only knows, perhaps,
what a number of nice, venerable, determined old gentlemen we have
here trying to manage our little medical world ; but many of us are
getting some inkling of their immeasurable and fathomless fatuity. It
appears, at any rate, that they are bound to destroy the Congress, for
they persist in forcing upon it restrictions which cut off from the Con-
gress and impugn the respectability of a large number of the most hon-
ored men in our profession. In thus doing they violate justice and
right, break the pledges at Copenhagen, and affront their fellow-physi-
cians here. Of course a bitter controversy is inevitable ; and we are
sorrowfully forced to the conclusion that there is at present no hope
tor the Congress whatever. The profession here and in other centers
362
MISCELLANY.
[N. Y. Mkd. JocH.r
is almost a unit against the policy of the association and its committee,
and it will continue to protest against the organization of a meeting
which will be so thoroughly misrepresentative of American medicine."
In another article the "Record" says:
" The real trouble in the case of the Washington Congress is that,
under the direction of a few gentlemen prominently interested in the
American Medical Association, the local issue of the code has been
forced upon an international scientific body. There was no justice or
right in this, and it was in violation of all precedent and of tacit
pledges made at Copenhagen. The consequence of their action is that
a large number of our country's best physicians are incapacitated from
holding any position in the meeting, and, of course, can not with self-
respect take part in the work of a body which impugns their profes-
sional respectability. The profession has almost unanimously con-
demned this action. In proof of this we give here a list, which we
believe is complete, of the journals in this country that have disapproved
of the course of the association : New York Medical Journal, Boston
Medical and Surgical Journal, The Medical Record, Chicago Journal
and Examiner, Maryland Medical Journal, Medical Age, Philadelphia
Medical Times, Louisville Medical Nevis, Atlanta Medical and Surgical
Journal, Virginia Medical Monthly, Indiana Medical Journal, Pacific
Medical and Surgical Journal, American Practitioner, New Orleans
Medical and Surgical Journal, Cincinnati Medical Journal, Columbus
Medical Journal, Medical News, Kansas City Medical Index.
" We believe that there is not one of the few medical journals that
defend the course of the present committee which has not some official
or close personal connection with the organization of the American
Medical Association and the Congress.
" There can thus be no doubt as to the sentiments of the profession.
It is impossible that this sentiment should be changed by the mere fact
that Drs. Cole and Shoemaker have been so completely effaced. This
•was a sop to the Philadelphia Cerberus ; but it was a mean act and will
win no support to the committee."
The " Medical News " publishes the following :
" At the stated meeting of the Luzerne County Medical Society, held
at Wilkesbarre on Wednesday, September 9th, the following resolu-
tions, offered by Drs. Mayer and Guthrie, were discussed and then car-
ried, but one vote being recorded in the negative :
" Whereas, The International Medical Congress is a scientific body
taking no cognizance of medical ethics or politics, therefore be it
" Resolved, That it is the sense of the Luzerne County Medical Soci-
ety that the officers and members of the Medical Congress should be
the most eminent representatives of the entire regular profession of our
country without regard to their views as to extraneous subjects.
" Resolved, That the action of our brethren of Philadelphia, and of
other cities, in declining to hold office in connection with the said Con-
gress as now proposed to be organized, and in protesting against the
method of its organization, is hereby heartily approved.
" In seconding the motion for the acceptance of the preamble and
resolutions offered by Dr. Guthrie, Dr. Mayer said :
" I desire to state that I had intended presenting to you to-day
other resolutions of similar tenor, but, upon learning of Dr. Guthrie's
purpose, will content myself with endeavoring to further the passage
of these, which I so highly approve.
"This whole matter referred to in the resolutions, when compressed
into a nutshell, would seem to be as follows : That the committee of
our National Association, originally appointed to secure a proper repre-
sentation of delegates and committees for the coming International
Congress, made selections which gave satisfaction to the best profes-
sional judgment of our country ; that then certain aspiring and neglect-
ed members of the association conspired at the last moment to exclude
from the appointed list a large number of men favorably known abroad
and distinguished at home for their zeal and success in scientific labors,
upon the plea that these gentlemen differed from the majority of the
association about ethical matters, well the subjects of legitimate con-
troversy. They succeeded in their plot, and in the enforced substitu-
tion for many honored names of others comparatively obscure. This
action has caused a profound sensation in medical circles, and has
aroused the best sentiment of the country in opposition to this usurpa-
tion. A large number of the ablest, the purest, and also the most con-
servative members of our profession, including, near at hand, such
lights as D. Hayes Agnew, Bartholow, Stille, Leidy, Mitchell, and Pep-
per, and at a distance other prominent men in New York, Boston, Bal-
timore, the South and the West, have combined in a protest against
this action of the Modified Committee, and have declined to fill the
positions assigned to them unless the original status of things be re-
stored. In the mean time some of the members of this committee are
inundating the land with proclamation and manifesto, and are endeav-
oring, by public circular and private solicitation, to whip and spur
county societies and individual members into adherence to their views.
"I trust that our society will now speak 'with no uncertain sound'
and place its stamp of reprobation upon this despotic attempt of a few
to coerce the many, and, by a unanimous vote, confirm the manly pro-
test made by our distinguished brethren in behalf of all that is broad,
high-toned, liberal, and free in American medicine. Its name has been
soiled in the dust of corrupt medical politics. Let us do our little to
help cleanse it."
The Chicago correspondent of the " Boston Medical and Surgical
Journal " writes :
" The International Congress, from the standpoint of the profession
here, has a gloomy outlook. We can not see how from the present
situation the gathering can be in any sense international. There may
be a large meeting, but if only American doctors attend, and if, as the
prospect is certain, many of the most distinguished members of our
own profession are absent, what is the use of a Congress at all ! Drs.
Lyman, Hyde, Jackson, Parkes, and Senn have publicly announced that
under the present organization they could not serve in the positions to
which they have been appointed. Not only have a large number of the
strongest men in the country declined to participate, but so large a
class that the idea is growing among the profession here that the Con-
gress will not be worth attending, that it is a foredoomed failure as an
international gathering. This feeling is heightened by the indications
from abroad of a growing sentiment of dissatisfaction with our ways
of doing, which is entertained by the profession of Europe, and which
promises to reduce to zero the 6mall delegation of eminent visitors we
had any reason to expect under the most favorable auspices.
" And the present prospects promise little for the amelioration of
the situation. We can see how some of the difficulties would disappear
if one side or the other would back down — a performance there is not
the smallest chance of our seeing. The leaders of the association move-
ment and the company of decliners to serve both belong to that class of
mankind who do not retreat easily ; they will not do it in this instance.
And even if they did, and mutually did, the injury done in Europe to
the prospects of the Congress are past repair. The spectacle is a hu-
miliating one for the American profession."
The " Western Medical Reporter " says :
"Our readers may have noticed in former issues of the 'Reporter*
a conspicuous absence of comments upon the war-cloud which now ob-
scures the bright horizon that erstwhile encircled the coming Interna-
tional Medical Congress. We assure our readers that our silence has
not been due to indifference upon our part, for the matter is certainly
one of vital importance to every medical man of a progressive mind.
There seemed, however, to be no probability that the prominent gen-
tlemen who are most closely identified with the best interests of the
American medical profession would so far forget themselves, and that
spirit of liberality and scientific progress which has been pre-eminently
the claim of the profession of the United States, as to seriously em-
broil themselves in a quarrel that could but engender the contempt of
the majority of the profession both at home and abroad ; we now, how-
ever, appreciate our mistake. To open the closet and exhibit to the
world the skeleton of the American medical family, ' the code,' was in-
deed in very poor taste to say the least, especially when such an exhi-
bition was absolutely certain to prove prejudicial to the coming Con-
gress. It seems a trifle peculiar that we Americans, with all our boasted
liberality and freedom of thought, should be the first to cast a stone at
the medical freethinker, and it may well seem a trifle paradoxical to
the scientific representatives of what we are prone to term the effete
governments of the Old World to find the future of the International
Congress endangered by the intolerance of American physicians.
" Our European brethren may perhaps appreciate the fact that the
Sept. 26, 1885.1
MISCELLANY.
363
American Medical Association in its action regarding the Congress has
not voiced the sentiments of either the majority or the best of the
members of the profession in America, but we are none the less dis-
graced in their opinion. It is perhaps wrong to lay this trouble at
the door of the association as a whole, for, as in every other organiza-
tion of a similar character, it will be found that the active management
is in the hands of a very few individuals ; but, as the matter now
stands, there is nothing else to bear the responsibility of the family
quarrel. With all respect to its venerable editor, the ' Journal of the
American Medical Association ' appears to be the only obstacle in the
way of an amicable rearrangement of the committees and a resump-
tion of the strictly scientific work which, if undisturbed, will make the
coming Congress fully as successful as any of those which have pre-
ceded it. Pertinacity is an excellent quality under exceptional circum-
stances, but in the present instance concessions for harmony's sake
would be in much better taste. The time is past for a body of men,
scientific or otherwise, to attempt to forcibly coerce the opinions of the
majority, and experience has taught the profession within a very few
years that the code question had better be left to take care of itself.
" The physician's own conscience is his most trustworthy mentor.
He may, from that purest of motives, honesty, decline to consult with
one whose views are so dogmatic and so diametrically opposed to the
results of scientific research that there could not possibly be any in-
terchange of ideas which would be liable to redound to the patient's
advantage. To accept a fee for such a consultation would be akin to
larceny. To consult with a man who meets a consultant, not as a
' -path 'or an ' -ic,' but as a respectable physician, is, however, above
reproach, whether both are recognized by the association or not. The
propriety of a consultation ought to be determined by the characteris-
tics of the men and not by the school which has empowered them to
practice. The relation of a certain proportion of physicians to the
mass of the profession is a trifle like the old story of the pigs in the
clover patch. They have protected themselves by a barbed-wire fence
denominated ' the code,' that plainly says to the fellows upon the out-
side, ' Thou shalt not steal.' The favored ones have always seemed to
be strangely familiar with the spaces between the wires, and, in case
their less fortunate brethren should find a few plums upon their side
of the fence, they have always been perfectly willing and eager to
rush out and help themselves ; now, however, that the outsiders have
shown themselves both able and willing to jump clear over the wires,
the protest of the fat fellows is most vehement. It is a singular fact
that the young man who graduates at a reputable college and settles
down in a new locality to earn his bread and butter will meet with less
courtesy and more bitter opposition at the hands of the gray-haired
adherents of ye venerable code than at the hands of the ' irregulars.'
We have known instances in which the aspirant to medical fame has
had his first cold-water bath at the hands of men whose names he had
been previously proud to read upon his diploma.
" How long the profession will continue to depreciate itself in the
eyes of the public by unseemly strife is a question, but the millennium
is devoutly to be prayed for. The explanation of the fact that the
medical profession commands so little respect at the hands both of the
laity and various municipalities is simply that its members are con-
tinually employed in cutting each other's throats. They are expected
to labor for nothing — or what is worse, glory — and to devote them-
selves to the welfare of a thankless public simply because there is not
among them sufficient professional esprit de corps to encourage them
to battle for their rights. Should a surgeon refuse to work for the
State, city, or any private corporation for nothing, or, at most, for a
mere pittance, there are a thousand others who will jump at the chance
if offered them. Doctors do sometimes refuse to accept glory from
conscientious motives, as is illustrated by the resignation of so many
gentlemen whose names graced the committees for the coming Con-
gress. As our respected contemporary, the ' Medical Age,' has aptly
remarked, ' even the Michigan men have resigned their exalted posi-
tions upon the committees, and when a Michigan man resigns an office
there must be something rotten in Denmark.' If the statement had
been a trifle more comprehensive, and had embraced the profession as
a whole, it would have been quite appropriate. There is no one, how-
ever, who is better qualified to express an opinion regarding the Wol-
verines than the editor of the ' Age.' We will live in the hope that
the cement of brotherly love will be spread on hot and thick at the
St. Louis meeting next year, and that certain prominent members of
the association may become quite expert in the use of the trowel by
that time. We fear, however, that there will be no peaceful interim
in which to practice the new and to them novel exercise. There are
others, too, who might find profitable employment in professional tail-
oring in order that our poor skeleton, the code, may be provided with
garments new wherewith to cover his unseemly nakedness, in case the
profession is bound to trot him out for the edification of the scientific
world at the next meeting of the association."
The Erie County Midwifery Law, passed at the last session of the
Legislature, reads as follows :
" Section 1. On or before the first day of July, eighteen hundred
and eighty-five, the county judge of Erie County shall, by an order to
be filed in the Erie County Clerk's Office, appoint a board of examin-
ers in midwifery to consist of five members who shall have been
licensed to practice physic and surgery in this State, and thereafter, as
often as any vacancy shall occur in said board, said county judge shall,
by a like order, fill such vacancy.
" Sec. 2. Immediately after the filing of said order said board shall
organize by the selection of one of its members as president, and of an-
other as secretary and treasurer, who shall hold their office for one
year, and be thereafter annually elected, and shall adopt and have power
to adopt and enforce such rules and regulations as are necessary to
carry out the purposes and provisions of this act.
" Sec. 3. Such examiners shall meet on the first Tuesdays of Octo-
ber and April in each year, and on such other days as such board may
appoint, in the city of Buffalo, after due notice thereof is publicly given
and shall then examine all candidates of the age of twenty-one vears
and upward, possessed of good moral character, who shall present
themselves to be examined for license to practice midwifery in the
county of Erie, and shall, on receipt of ten dollars, issue their certifi-
cate to any person so examined who shall be found by them to be quali-
fied, which certificate shall set forth that said board has found the per-
son to whom it is issued qualified to practice midwifery, and shall be
recorded by the clerk of the county of Erie in a book to be kept by
him for that purpose. All moneys going into the treasury of this board
shall be applied to defray the expenses of this board.
" Sec. 4. Any person who has received and recorded such certificate
shall thereupon be designated a midwife, and authorized and entitled
within the county of Erie to practice midwifery in cases of normal
labor, and in no others ; but such persons shall not in any case of labor
use instruments of any kind, nor assist labor by any artificial forci-
ble, or mechanical means, nor perform any version nor attempt to re-
move adherent placenta, nor administer, prescribe, advise, or employ
any poisonous or dangerous drug, herb, or medicine, nor attempt the
treatment of disease, except where the attendance of a physician can
not be speedily procured, and in such cases such persons shall at once,
and in the most speedy way, procure the attendance of a physician.
" Sec. 5. Said board of examiners shall have power, on proper
cause shown and after hearing the person holding their certificate to
recommend to the county judge of Erie County the revocation of the
same, and said judge shall have power to revoke such certificate and
license.
" Sec. 6. Any person who shall practice or, without the attend-
ance of a physician where one can be procured, attend a case of mid-
wifery or obstetrics within the county of Erie after the thirty-first day
of December, eighteen hundred and eighty-five, without being dulv au-
thorized so to do under existing laws of this State, or without having
received and recorded the certificate provided for by this act, and any
person who shall violate any of the provisions of this act, shall be
guilty of a misdemeanor, and, on conviction thereof, shall be fined not
less than fifty dollars nor more than one hundred dollars, and shall for-
feit any certificate theretofore granted under the provision of this act.
"Sec. 7. This act shall take effect immediately."
The first meeting of the board (consisting of Dr. M. D. Maun, presi-
dent, Dr. J. H. Pryor, secretary, Dr. H. R. Hopkins, Dr. I». \V. Van
Peyma, and Dr. J. W. Keene) for the purpose of examining candidates
36*
will be held Tuesday, October 6tb, between the hours of 3.30 and 6 P. m.,
at the Fitch Institute. If necessary, the board will meet on other days,
which will be announced. Any person applying for examination must
furnish satisfactory evidence that she is of good moral character,
twenty-one years of age, or more, and has attended, or assisted in at-
tending, ten or more cases of labor. The examination will be both
written and oral, and the answers to questions must be written or
spoken, as the board may direct. Applicants will be examined in Eng-
lish or German, as they may desire. It will be the aim of the board to
determine whether a candidate is competent to fulfill the requirements
and instructions of the law as stated in Sections 3 and 4, and the char-
acter and scope of the examination will be planned with that intention.
The candidate must possess a knowledge of the following essential sub-
jects: The structure of the external and internal parts of the female
generative organs and pelvis. The symptoms, mechanism, course, and
management of natural labor. The symptoms and indications of compli-
cated or abnormal labor, and the emergencies which render it necessary
to seek a physician's advice. How to care for the mother and child
after the child is born. The hygiene of the sick-room, including clean-
liness, etc. The prevention of disease, and how to avoid infection and
contagion.
Further information can be obtained by applying to the secretary,
J. H. Pryor, M. D., 327 Franklin Street, Buffalo.
The French Society of Otology and Laryngology, as we learn from
the "Union medicale," will meet in Paris on the 8th, 9th, and 10th of
October.
Preservative Solutions for Embalming. — Santer (quoted in " Union
medicale ") recommends, for temporary use, injecting the vessels with
the following solution :
Carbolic acid 1 part ;
Glycerin 10 parts;
Alcohol 5 "
Water . . 40 "
If permanent preservation is desired, this is to be followed by a co-
pious injection of a one-to-two solution of chloride of zinc colored with
fuchsin, or of a solution (strength not stated) of sulphate of albumin
[y aluminium] colored with cochineal. The surface of the body is then
to be coated with vaseline or with a sandarac varnish containing car-
bolic acid, the cavities being filled with cotton treated with corrosive
sublimate or soaked in a five-per-cent. glycerin solution of carbolic
acid.
The Leuval Prize for an Improved Instrument for Deafness. —
Baron Leon de Leuval, of Nice, has offered, through the Third Interna-
tional Congress for Otology, a prize of 3,000 francs for the best porta-
ble instrument, constructed on the principle of the microphore, for the
improvement of hearing in cases of partial deafness. Instruments in-
tended for competition must be sent before December 31, 1887, to one
of the members of the jury appointed to decide upon their merits. The
jury consists of Prof. Hagenbach-Bischoff, Ph. D., M. D., chairman of
the jury, Basle (Missionsstr. 20); Benni, M. D., Warsaw (16 Bracka);
Prof. Burekhardt-Merian, M. D., Basle (42 Albanvorstadt) ; Gelle, M. D.,
Paris (49 Rue Boulard) ; Prof. Adam Politzer, M. D., Vienna (I Gonza-
gagasse 19). Perfected instruments only are to be considered, and
with reference particularly to their mechanical construction, the proper
application of the laws of physics and their power to improve the hear-
ing. The prize will be awarded at the Fourth International Congress
for Otology, to be held in Brussels in September, 1888. If none" of the
instruments presented are considered worthy of the prize, the competi-
tion will be kept open until the meeting of the Fifth Congress.
Companion for an Invalid. — An English lady, of extensive experi-
ence in the care of the sick, writes us that she is desirous of obtaining
a position as traveling companion to an invalid, and that she is willing
to come to America for the purpose of accompanying such an one back
to Europe. We shall be happy to furnish her address to any of our
readers who may wish to secure her services.
The American Public Health Association will hold its thirteenth
annual meeting in Washington, D. C, December 8, 1885. The Local
[N. Y. Mki>. Jot u
- »
Committee intrusted with perfecting arrangements for the meeting,
which includes transportation and entertainment for the members of
the association and place for holding the sessions, is as follows : Dr.
Smith Townshend, chairman; Dr. J. C. McGinn, secretary; Dr. J. S.
Billings, U. S. A. ; Dp" John M. Brown, U. 8. N. ; Mr. William P. Dun-
woody, National Board of Health ; Hon. John Eaton, Sr., Prof. John
Gamgee, Dr. A. Y. P. Garnett, Dr. A. L. Gihon, U. S. N. ; Dr. Walter
Gwynn, Dr. Charles H. H. Hall, U. S. N. ; Dr. C. G. Hirndon, U. S. X. ;
Dr. Adrian Hudson, U. S. N. ; Mr. E. S. Hutchinson, Dr. J. H. Kidder,
U. S. N. ; Dr. William Lee, Dr. George B. Loring, Dr. De Witt C. Pat-
terson, Dr. Stephen O. Richey, Dr. Charles Smart, U. S. A. ; Dr. Thomas
J. Turner, U. S. N. ; Dr. J. M. Toner, Dr. P. S. Wales, U. S. N. ; Dr.
Ralph Walsh, Dr. Charles H. White, Dr. T. S. Verdi, Mr. Samuel A.
Robinson, and Dr. D. E. Salmon.
Extract of Pinus Canadensis. — Dr. C. H. Davis, of Tunkhannock,
Pa., writes to the Rio Chemical Company as follows :
" I can speak positively of the great value of Kennedy's extract of
pinus canadensis. I have been treating a case of piotruding piles of
twenty years' standing, making life almost intolerable at times ; they
have been treated for years with only palliative results. About a year
ago an operation was submitted to, since which time the tumors have
remained smaller and less sensitive, but a new trouble soon set in,
namely, itching to a terrible extent, which nothing seemed to relieve
until I tried the extract of canadensis, two parts to one of gl)-cerin, two
or three applications of which relieved the itching entirely, and the dis-
ease is being rapidly benefited in every way. Have used it only once a
day after each evacuation. I find it an excellent remedy in leucorrhoea
also."
THERAPEUTICAL NOTES.
The Physiological Action of Hydrastis Canadensis. — Fellner (" Med.
Jahrb." ; " Ctrbl. f. Gynak.") has found, by experiments on dogs and
rabbits that golden seal gives rise to changes in the blood-pressure and
in the action of the heart. Increase of the blood-pressure arises chiefly
from contractions in the vascular system, and its decrease from paraly-
sis of the vaso-motor centers, dilatation of the vessels, and retardation
of the pulse. The depressor nerve has no influence upon a diminution
of the blood-pressure induced by hydrastis, although in the vascular
areas of the splanchnic and other nerves contractions and dilatations
occur. If large and then small doses are injected while the aorta is
compressed above the diaphragm, the pulse is alternately retarded and
accelerated; and this is followed by tumultuous action of the heart and
its exhaustion and paralysis. The action of hydrastis, whether irrita-
tive or paralyzing, is not confined to the vaso-motor nerve centers, but
it acts also upon the cardiac ganglia ; it is therefore a cardiac as well
as a vascular poison. The drug acts upon the muscular tissue of the
uterus as it does upon the blood-vessels, causing contraction and relaxa-
tion. In certain cases this action may be observed even in the small
intestine. From one to two drops of a ten-per-cent. solution of hydro-
chlorate of hydrastine, injected subcutaneously, give rise to energetic
uterine contractions. According to the author, this salt and phosphate
of berberine should be used in practice, as, in small doses, they exert
the same action as the fluid extract of Hydrastis canadensis.
Capsicum in the Treatment of Delirium Tremens is no novelty,
but the large doses used by Dulacska (" Pest, med.-chir. Presse " ;
" CtrlbL f. kl. Med.") are noteworthy. He used the drug in four cases,
one of which was complicated with pneumonia. Thirty grains of the
powder were given every hour. After four doses had been taken, sleep
took place, followed by profuse sweating and urination, and often by
an alvine evacuation. The author attributes the effects to the action
of the remedy on the intestinal nerves, but he did not observe any in-
testinal derangement result from its use.
Cocaine in Seasickness, — Manassein ("Berlin, kl. Wchnschr.";
" Lancet ") has used the following solution in several cases with grati-
fying results :
Hydrochlorate of cocaine 2J grains ;
Alcohol q. s. ;
Distilled water 4 J ounces.
He gives a teaspoonful every two or three hours.
MISCELLANY.
THE TOW YORK MEDICAL JOURNAL, October 8, 1885.
fee hires auir % r c sscs .
AN ADDRESS
DELIVERED BEFORE THE NEW YORK ACADEMY OF MEDI-
CINE, OCTOBER 1, 1885,
BY THE PRESIDENT,
ABRAHAM JACOBT, M. D.
Fellows of the New York Academy of Medicine :
It is a source of intense gratification to me to greet you
this evening in the beginning of a new season of co-opera-
tive work, after a long vacation. May the labor of the
coming months be successful both for ourselves and for the
medical world, ars longa, vita brevis. Art is so extensive
indeed and life so short that we have to concentrate all our
efforts to accomplish a certain amount of result.
In behalf of our common interests I crave your atten-
tion first to a few facts which I consider of great importance
in regard to medical progress. They are connected with
the session of the International Congress held in Copen-
hagen from the 10th to the 16th of August, 1884. In a
general meeting held on August 14th, upon propositions
made by Sir James Paget, of London, Prof. Ewald, of Ber-
lin, Prof. Bouchard, of Paris, and Dr. Billings, of Washing-
ton, the following resolution was passed : That an interna-
tional committee be formed for the collective investigation
of disease, in connection with the work of the International
Congress, and that a certain number of gentlemen do repre-
sent their respective countries thereon. The gentlemen
designated for that purpose were Trier and C. Lange, of
Copenhagen ; E. Bull, of Christiania ; Rauchfuss, of St. Pe-
tersburg ; Ewald and Bernhardt, of Berlin ; Schnitzler, of
Vienna; Pribram, of Prague; Koranyi, of Buda-Pest ;
D'Espino, of Geneva; Bouchard, of Paris; Lepine, of Ly-
ons ; Sir William Gull and Mahomed, of London ; Humph-
ry, of Cambridge ; Sir Joseph Fayrer, for British India ;
Gutierrez-Ponce, for South America ; N. S. Davis, of Chica-
go ; A. Jacobi, of New York ; and Isambard Owen, Secre-
tary-General, of London. The only changes which have
since taken place in the list of membership have been
brought about by the untimely death of Dr. Mahomed, and
the addition of Axel Key, of Stockholm, and Runeberg, of
Dorpat.
According to a circular distributed by the Secretary-
General some time ago, "the main objects which the com-
mittee seeks to attain through the collective investigation of
disease are to widen the basis of medical science, to gather
and store the mass of information that at present goes to
waste, to verify or correct existing opinions, to discover
laws where now only irregularity is perceived, to amplify
our knowledge of rare affections, and to ascertain such
points as the geographical distribution of diseases and their
modifications in different districts. It will be its endeavor
to place clearly before the whole profession the limits and
defects of existing knowledge, as well as to stimulate obser-
vation and to give it a definite direction. It will be a not
unimportant incidental result of its work should it tend, as
is hoped, to the better training of the members of the pro-
fession in habits of scientific and practical observation, and
in systematic methods of recording the facts which they
observe.
The age in which we live has seen enormous advances
in the sciences on which the fabric of medicine rests — such
as chemistry and other branches of physics, physiology, and
pathology. Each of these has taken giant strides. It must
be admitted, however, that purely medical knowledge has
scarcely made proportionate progress. It can not be ex-
pected that it should do so, as it deals with the aberrations
of the most complex of organisms, is of all sciences the
most difficult, and demands the greatest patience and the
largest accumulation of data.
Hitherto the advancement of medical science has been
brought about mainly by individual effort. The value of
such work in the past we in no way underrate, nor do we
desire to lessen the amount of it in the future ; but in medi-
cal science there is much that defies interpretation from in-
dividual experience, and many problems so far-reaching in
an ever-widening field, with elements so manifold that no
single man, however gifted and long-lived, can hope to bring
the whole within his range. The need, therefore, in medi-
cine of that combination and concentration of individual
work which is adopted in many other branches of science
and in commerce, and to which increasing facilities of in-
tercommunication have given so much impulse and so much
strength, can not be questioned. Indeed, it may be said
that, resting on individual research alone, medical knowl-
edge can be advanced but slowly and with difficulty. Fu-
ture progress to any great extent must be the work, not of
units acting disconnectedly, but of the collected force of
many acting as one. For many to act as one, organization
is needed ; that organization it is the purpose of our com-
mittee to supply.
Disease is many-sided, and we wish to include in our
organization those who see it from every side. All, there-
fore, whether hospital physicians, family and school attend-
ants, specialists, medical officers of the army and navy and
of workhouses and asylums, will be asked to contribute
their quota of observations to the common fund.
These are both the motives and the propositions of
the committee appointed at Copenhagen. In regard to
them, and collective investigation in general, the favorable
opinion of the profession has been expressed frequently.
But now and then a voice is still heard disparaging its util-
ity, and discouraging the collection of facts on a.large scale
for the reason that the procedure has not yet been demon-
strated to be useful. Indeed it has not, for it has never
been tried to a large extent. We shall hardly insist, how-
ever, that the ground-stone must not be laid because the
tower is not yet on the edifice ; that the seed must not be
sown because the fruit can not be harvested to-day, or was
not gathered yesterday.
Hesitation has also been expressed from another point
of view. One of our foremost medical journals (" Boston
Medical and Surgical Journal" of September 4, L884)
makes the remark that those who labor only for personal
366
J A GOBI: AN ADDRESS BEFORE
THE ACADEMY OF MEDICINE. [N. Y. Meu. Jodk.
renown will not enter enthusiastically into the work pro-
posed by the committee. But its demands are very trifling
indeed, the questions to be settled by the observations of
large numbers are but few, and of such a nature as not to
expropriate those who are able and anxious to arrive at and
be credited with scientific results of their own, and benefit
by the reputation attached to them.
If the remarks above quoted were founded on reality,
whoever worked for personal reputation only would not
even participate in the discussion of a scientific society, for
fear that his remarks, coupled with the essay of somebody
else, would miss the opportunity of being listened to as the
main topic of an evening's conversation. Now, on the con-
trary, we are in the daily habit of seeing experience pub-
lished and ingenuity displayed in just such discussions.
Nor do I believe that, as another journal has it (" New
York Medical Journal," September 4, 1884), "the answers
coming from a great body of men of diverse views would
constitute but a catalogue of raw impressions," and that,
" when the facts to be observed are of a nature to call for
exquisite discrimination on the part of the observers, to
multiply the number of the observers is to depreciate the
general quality of the work." For the more uncertain the
correctness of observations is apt to be, the more numerous
they ought to become. Single observations have settled a
fact but very rarely. The very existence of large societies
proves the instinctive demand for variety and comparative
appreciation of observations. Is not every physiological fact
kuown to us the outgrowth of a number of experiments of
many men ? and pathological knowledge the result of a
great many autopsies by different men in many countries ?
What is individual experience but the accumulation of a
multitude of facts of a similar nature by one man? What
is science but the result of accumulated experience, collected
and compared, of many men, countries, and ages ? Are a
hundred meteorological stations more efficient or less so
than one would be ? I do not belong to that class who be-
lieve a problem easy of solution merely because its solution
is anxiously sought for, nor do I deny difficulties because
they are obstacles to the accomplishment of cherished ends,
but I know that we are in a better position to serve the co.
operative work of all countries now that steam and telegraph
have reduced distances, mail and travel have multiplied in.
tercourse, and we are to-day as near St. Petersburg as our
ancestors were, a hundred years ago, to Lake Erie or the
James River.
Thus it appears evident that the difficulties are not ex-
cessive. As to the usefulness of collective investigation,
the opinions will become all but unanimous. The efforts
of the British Medical Association and the Medical Society
of Berlin, and the fair success of an attempt at solving a
problem connected with the aetiology of croupous pneu-
monia, made in the Medical Society of the County of New
York during the last year, are sufficiently promising for
the collective investigations of the future. In their interest
it is that I propose to make a further communication and
request your co-operation.
The Central Committee on Collective Investigation of
the International Congress has selected the following sub-
jects, viz. : Rickets, chorea, acute rheumatism, and cancer,
planned a number of simple questions in regard to them,
mainly to their aetiology, and expects as simple answers.
Being the secretary of the American sub-committee, I have
gathered all of them in pamphlet form, added a few intro-
ductory general remarks, supplied by the Central Commit-
tee, and present herewith a specimen for your inspection.
Those of you — I hope all of you — and those of the profes-
sion at large who will learn of this request, are respectfully
asked to interest themselves and their friends in behalf of
the undertaking, notify me of their desire to be furnished
with a copy, and comply with the suggestions of the com-
mittee contained therein. We do not look for immediate
achievements. For the complex of sciences and arts called
medicine has required thousands of years to arrive at
its present condition ; the aggregation of many wills and
forces has resulted in a slow evolution only. No single
discovery even, nor the first attempts at collective investiga-
tion, will effect a revolution in medicine. But what we do
hope to accomplish is the gathering of facts on the strength
of an improved method, the confirmation of old and the
acquisition of new knowledge, and thus to contribute to
the success of at least this one committee. It need not
matter how much may have, nay, has, been done to mar
the success of the next International Assembly, and to de-
prive us of the opportunity long looked forward to of greet-
ing the giants of science, the celebrated teachers, the in-
genious experimenters, and our literary or personal friends
of Europe, on our own soil. For an International Con-
gress will never convene under the roof of a house divided
in itself, though the division may be the wTork of a few sac-
rilegious hands only.
But this is a sad theme, known to everybody here, de-
plored by everybody who feels as both a personal grief and
a public calamity the humiliation which is involved in the
hesitation on the part of the Congress to assemble in our
country.
It is in profound sorrow that I pass by the subject ; I
prefer to speak of another topic, which, while it is not di-
rectly connected with any of the aims and immediate pur-
poses of this Academy, concerns us as professional men of
the State of New York and the Union. I allude to the al-
most unexpected success on the part of the profession of
the State of New York in harmonizing a large majority of
the medical men of the United States.
Let me explain. Chap. II, Art. IV, Sec. 1 of the Code
of Ethics of the American Medical Association reads as fol-
lows : " A regular medical education furnishes the only pre-
sumptive evidence of professional abilities and acquirements,
and ought to be the only acknowledged right of an indi-
vidual to the exercise and honors of his profession. Nev-
ertheless, as in consultations the good of the patient is the
sole object in view, and this is often dependent on per-
sonal confidence, no intelligent regular practitioner, who
has a license to practice from some medical board of known
and acknowledged responsibility recognized by their asso-
ciation, and who is in good moral and professional stand-
ing in the place in which he resides, should be fastidiously
excluded from fellowship, or his aid refused in consultations
Oct. 3, 1885.] JACOBI: AN ADDRESS BEFORE
TEE ACADEMY OF MEDICINE.
367
when it is requested by the patient. But no one can be
considered as a regular practitioner, or a fit associate in
consultation, whose practice is based on an exclusive dogma,
to the rejection of the accumulated experience of the pro-
fession, and of the aids actually furnished by anatomy,
physiology, pathology, and organic chemistry."
This paragraph has so often been criticised by both
friends and adversaries that it is unnecessary to refer again
to its contradictions, its "nevertheless" and "but," and to
its implied acknowledgment of modern " homoeopathy."
For let us not forget that the code of ethics of the Ameri-
can Medical Association saw the light forty years ago, and
that what they call " homoeopathy " nowadays differs from
the Hahnemannism of those times in everything but the
name. They now maintain that their practice is not based
on an exclusive dogma ; they profess to teach in their
schools — and do teach — anatomy, physiology, pathology,
and organic chemistry, and thus come up to the require-
ments of the above-quoted article of the code of ethics of
the American Medical Association. Indeed, if there were no
better grounds for their rejection, they would to-day be en-
titled to membership in the association.
What the Medical Society of the State of New York, in
its sessions of 1882 and 1883, adopted in its stead ("Trans,
of the Med. Soc. of the State of New York " for the year
1882, p. 75), in a code of medical ethics which covers two
pages instead of the eighteen pages of the code of medical
ethics of the American Medical Association (" Proceedings
of the National Medical Conventions, held in New York,
May, 1846, and in Philadelphia, May, 1847," Philadelphia,
1847, pp. 91-106), reads as follows :
" Members of the Medical Society of the State of New
York, and of the medical societies in affiliation therewith,
may meet in consultation legally qualified practitioners of
medicine. Emergencies may occur in which all restrictions
should, in the judgment of the practitioner, yield to the
demands of humanity."
Compare with these brief sentences the explanatory dec-
laration of the American Medical Association, passed unani-
mously in its session at New Orleans of April 30, 1885.
There and then it was " Resolved, That clause first of Art.
IV in the National Code of Medical Ethics is not to be in-
terpreted as excluding from professional fellowship, on the
ground of differences in doctrine or belief, those who in
other respects are entitled to be members of the regular
medical profession. Neither is there any other article or
clause of the said code of ethics that interferes with the ex-
ercise of the most perfect liberty of individual opinion and
practice.
" 2. Resolved, That it constitutes a voluntary disconnec-
tion or withdrawal from the medical profession proper to
assume a name indicating to the public a sectarian or exclu-
sive system of practice, or to belong to an association or
party antagonistic to the general medical profession.
" 3. Resolved, That there is no provision in the National
Code of Medical Ethics in any wise inconsistent with the
broadest dictates of humanity, and that the article of the
code which relates to consultations can not be correctly in-
terpreted as interdicting, under any circumstances, the ren-
dering of professional services whenever there is pressing or
immediate need of them. On the contrary, to meet the
emergencies caused by disease or accident, and to give a
helping hand to the distressed without unnecessary delay,
is a duty fully enjoined on every member of the profession,
both by the letter and the spirit of the entire code.
" But no such emergencies or circumstances can make
it necessary or proper to enter into formal professional con-
sultations with those who have voluntarily disconnected
themselves from the regular medical profession, in the man-
ner indicated by the preceding resolution."
After these resolutions had been passed in New Orleans
many of the professional men who always persisted in ad-
hering- to the code of the American Medical Association
were of the honest opinion that they had, by accepting
them, removed every discrepancy of opinion or difference
of action on the part of those adhering to either the old or
new code. For it is true that the explanatory declaration
of Chap. II, Art. IV, Sec. 1, exhibits a great resemblance
to the New York Code of 1882. For the Medical Society
of the State of New York it must be a source of intense
gratification to be convinced by the passing of that declara-
tion that a few years have sufficed to so change public opin-
ion as to oblige even the American Medical Association to
recognize the justness of most of the New York proceedings.
Upon this result the New York State Society can but be
sincerely congratulated, and the spirit of equity and justice
as displayed by the committee drafting the explanatory
declaration must be commended.
The expressions of opinion in regard to the wholesome
effect of the New Orleans declaration have been very nu-
merous. I am in possession of several letters containing
remarks full of satisfaction and hope. A gentleman well
and deservedly known in the professions of both hemi-
spheres, and markedly so with us for his allegiance to the
code of ethics of the American Medical Association, gave
enthusiastic expression to his delight over the satisfaction
that declaration must give, and to the hope that the New
York Academy of Medicine would give a public utterance
in that direction. That would " immediately settle all diffi-
culty about the code, and at once restore peace and har-
mony in the profession." I had to tell him that the Acad-
emy excluded all politics, ethical or other, from its discus-
sions, and that the only societies which could act in the
matter were the medical societies of the county and of the
State of New York. There the matter then rested, for I
believe I was right in excluding it from any consideration
in our midst.
Still, while this Academy is no political body, old and
new codes, as far as I know, being equally represented with
us, we are an integral part of the body medical, and the
events in the professional world affect our interests and
sympathies intensely. Thus we have to regret that the
wording of the resolutions of New Orleans is very likely to
obscure their meaning. Emergencies are acknowledged to
be binding, but, while the New York code admits that a
physician may (not shall, or must) consult with a legal prac-
titioner in a case of emergency, the explanatory declaration
of the association insists that such a meeting is not a meet-
368
J AC OBI:
AN ADDRESS BEFORE
THE ACADEMY OF MEDICINE. [N. Y. Med. Joi n.,
ing in the usual meaning of the term, and such a consulta-
tion " no formal professional consultation."
The differences are rather slight, it is true. If, in spite
of that, the code question is still made a war-cry by some,
that fact reminds us of the bloody wars and persecutions
directed against former friends because of nominal differ-
ences of eccleciastical opinions in the history of the church-
It is also explained by the intense enmity exhibited under
all circumstances by those who have been convinced against
their will. In a few instances we have to deal with the
zeal displayed by converts who, after they had greeted the
birth of the new code with congratulations, were induced,
by certain external circumstances, to change what they call
their minds within the period elapsing between the appear-
ance of two monthly numbers. Or, what is still more —
shall I say surprising, shall I say sad ? — there are those who
fought the new code because they longed for a fight with-
out caring on what account. A gentleman who edited an
upright and rattling journal at that memorable time, and
voted " the regular ticket," and was by no means gentle
toward the new-code men and principles, has convinced and
assured me he never read the new code. I believe him.
There are others again — their number has been large at all
times — whose souls and sensibilities are moved by shibbo-
leths, by single words, provided these words are skillfully
handled by shrewd calculation.
" Just where fails the comprehension
A word steps promptly in as deputy.
With words 'tis excellent disputing;
Systems to words 'tis easy suiting ;
On words 'tis excellent believing ;
No word can ever lose a jot from thieving."
— Bayard Taylor's "Faust."
This is the element which, in skillful hands, determines
for a moment the result of meetings, caucuses, assemblies.
It is the emotional element, which is swayed by sentiment
both false and true, by gesticulating oratory, and by im-
plicit temporary confidence in the veracity and sound mo-
tives of its presumed leaders, which, therefore, " takes the
specialists of the new-code persuasion by the tops of their
heads and cuts their throats," but, after all, is cooled down
by common sense, consciousness, and conscientiousness,
when left to itself. Such men are in the majority. They
are the waves of the ocean, always changing, now smooth
and smiling, then turbulent and raving, and still always the
same, steady in their general effects, now and then a dis-
turbance and an injury, but always the eternal source of
healthful development. We never cease to bless the ocean,
even when it is doing its temporary worst. Let us, there-
fore, not despair of the future peaceful and blissful devel-
opment of the country or the profession in times of turbu.
lent commotion.
What difference is left unabolished may be left to itself
until acrimony is soothed and bitterness replaced by kind-
ness. Greater discrepancies than these have been wiped
out. When the actions of men are weighed, their opinions
in regard to dogmatic utterances will be disregarded.
When deeds are counted, let creeds be tolerated. But let
us have patience, all of us; great improvements in the uni-
versal conscience do not take place by hard fighting and'
refuting. Lecky is right when he says that the greatest
errors can not be annihilated ; it takes time for them to fade
out.
In the face of the explanatory declaration passed in New
Orleans which, in its main aspects, I take it, indorses the
New York State Society and the spirit of the new code, the
majority of those present in the meeting of the American
Medical Association were guided into believing that they
must protect a sacred code from infidel invaders. The main
complaint was that new-code men had been given offices in
the organization of the International Congress. On page
101 of the "Journal of the American Medical Association"
you will find the following complaint : "Directly upon the
threshold of the most important part of their work a ma-
jority of the original committee practically ignored all alle-
giance to the American Medical Association, and, assuming
an entirely independent attitude, at once placed in the front
of their ranks . . . one who was well known to have re-
pudiated the National Code of Ethics." And, in a volu-
minous circular addressed to State and county medical so-
cieties, composed almost exclusively of editorials of the
" Journal of the American Medical Association " and signed
by the permanent secretary of the association and four
other gentlemen, the following language is used : " The
editorials of the 'Journal of the Association' . . . pre-
sent the case " (the differences in regard to the proposed
organization of the International Congress) " so clearly
that there can be no doubt of the duty of the friends
of the association, or of the animus of its enemies. We
feel assured that your society will indorse the action of the
Association, and stand firm in support of the Code of
Ethics."
It is, however, fairly understood by this time that the
war of the codes is over. In fact, it has always appeared to
unsophisticated people that the fighting about the code was
not reciprocal at all ; for when the New York State Society
had settled its code question to its satisfaction and that of
the country societies in affiliation therewith, it appears that,
in them and by them, the subject was not mentioned again
except on strong provocation. You remember that it took
a great deal of emphasis to relieve even this Academy of
the proffered dispute. The code question is dying a great
deal more easily than the bloody shirt disappeared from the
politics of the country. If it is puffed up as the pivot of
the organization of the International Congress, everybody
is perfectly aware that this is either a pretext or a grave
mistake. I believe it is both. Europeans, who were not
afraid of admitting laymen and homceopathists, expected
to meet, if ever they should consent to cross the Atlantic
for an International Congress, the American medical pro-
fession. No International Congress must be caught in do-
mestic quarrels, or audaciously kidnapped by a society, or a
party, or the faculty of a medical school.
We are presenting a sad spectacle. In our first attempt
at welcoming the medical world to our shores we have
failed. The humiliation connected with this fact we have
to submit to ; to trace it to all its causes I can not under-
Oct. 3, 1885.]
JACOBI: AN ADDRESS BEFORE THE ACADEMY OF MEDICINE.
360
take here. The least we can do is to admit it ; if the task
we hoped to accomplish was too much for us, let us try to
prepare for the future by attending to those duties of our
own which we can perform without hindrance or disturb-
ance.
The affairs of the Academy will require our undivided
attention. In many respects we have been very successful
indeed. The hall and building- in which we meet is prac-
tically our own and free of debt. Thus we can look for-
ward again to improve our quarters, enlarge our facilities,
and think of securing in some near future a fire-proof build-
ing for our ever-increasing bibliographical treasures. Our
income has increased with our membership. Both, how-
ever, require additions. There are many desirable men in
the profession whom we ought to carry on our lists for
mutual advantage.
The hopes I expressed in my inaugural address a few
months ago have begun to be fulfilled. Old sections have
been revived, new ones have been formed. I may here as-
sure the gentlemen who have undertaken the task of organ-
izing them that whatever aid the President and Council
can give them in their labors will be freely offered. The
sections will not only contribute to the improvement of their
own members, but will enhance the interest of the general
sessions by the communications coming to them from the
sections, and the discussions emanating therefrom.
To enable them to begin their work, Article VI of the
Constitution had to be altered. That change was brought
about, in the manner prescribed by law, some months ago.
It has also appeared to many fellows that more alterations
are required ; they have given notice of their desires in this
respect, but have been unwilling to come before the Acad-
emy with any propositions to make radical changes, though
in the manner prescribed by law. Now, both the constitu-
tion and by-laws may be repealed or amended by a three-
fourths vote at a stated meeting, provided notice of the
same has been given in writing at a previous stated meet-
ing. But it will prove more satisfactory to guard against
any mistake by trusting the work of moving proposals to
change our by-laws in the hands of a committee carefully
selected for that purpose. Off-hand legislation is always
dangerous ; it often errs, and always weakens the conserva-
tive tendencies which must underlie any political, scientific,
or social structure if it is expected to last. The president
expresses the hope that, if such a committee is appointed, it
will be slow in considering and quick in reporting. If I
am at liberty to state a wish of my own, I should say that
one of the articles which require amending is that which
refers to the Committee on Medical Ethics. This commit-
tee is almost powerless ; it has no initiative whatsoever ; in
every case calling for interference or judgment, it has to
wait for a charge to be preferred by a fellow ; the odium of
an accusation falls always on' an individual member, whose
unselfish interest in the welfare of the Academy or the pro-
fession is at once published, as it were, by arraying him
personally against the accused. To prefer a charge is thus
almost rendered an impossibility. Thus, indeed, our law is
more apt to encourage derelictions of ethical duties than to
prevent or punish them. Now, I am of the opinion that
the interest of an accused must always be taken into account,
but that that of the Academy is at least of equal impor-
tance. What the district attorney and the police are in the
political and social commonwealth, the Committee on Ethics
ought to be in our midst. It ought to be both authorized
and directed not to wait for personal charges, but itself
watch over the moral welfare of our community. If such
an authority is established, the ethically weak will know
that he is observed, and may be held responsible without a
fellow being compelled to draw upon himself odium or
revenge.
No society, either political or other, can ever do with-
out a penal code — old or new ; thus there is no harm in ad-
mitting that the Academy is in need of a committee on
ethics like any other society. If the number of those who
necessitate its existence or interference is but small, so
much the better; but the few, when not stopped, act as
bacilli of moral putrefaction. Human kind is so organized
that disease-germs will operate rapidly and persistently. A
committee on ethics endowed with the authority to warn
and censure in time, without any procrastination, will
strengthen the feeble when he feels the first symptoms of
struggling against temptation, may frighten the man of
harder fiber who would otherwise rely on his facilities and
the difficulties on the part of the committee, and protect
the interest of society and the endangered dignity of the
profession.
That I speak of no imaginary evil we all know too well.
What I said a few months ago of the growing tendency of
a few to make the public acquainted with their merits and
accomplishments through the columns of the secular press
was considered timely and met with the appreciation of
many members of the profession, both old and young, here
and elsewhere. I mean to deserve the respect of my peers
and superiors in the profession by again directing your at-
tention to the fact that the penny-a-liners of the daily press
are being utilized in the interest of, and by, weak-kneed
brothers who can not stand on their own legs, who mistake
cheap notoriety for reputation, and the grin of derision for
the smile of approval. The more power is concentrated in
commerce, the greater the prevalence which is conquered
by trade, the more rampant the spirit of grasping egotism
which is pathognomonic of modern industrial pursuits, the
more is it the domain of the liberal professions to approxi-
mate their aims to an ideal. Let us not forget that learn-
ing by heart the action of medicines, or the working of
articulations, or the proper use of an instrument, does not
exhaust the possibilities of a medical man. The physician
requires all that, but beyond that all the characteristics of a
man of principle and intellectual and moral culture. Neither
can be inculcated by the demands of old or new codes.
Still, as a corporation and a profession, we are responsible
for the existence of these qualities in our members. It is
true, we can not supply ideals to order, nor can we make
those whose eyes seek the mire raise their brow to the
skies. But such as find it difficult to develop those quali-
ties spontaneously must be taught and aided in acquiring
them.
As far as I am concerned, I hope there will be no occa-
370
WILLIAMS: PNEUMATIC DIFFERENTIATION.
[N. Y. Mei>. Joi k.,
sion again to refer to the same subject during my term of
service. If there is, I shall repeat my warning ; for I take
it for granted that when you elected me to the highest
office in your possession you did so both in the belief that
your candidate would have opinions and principles of his
own, and on the condition that he should do his full duty.
#righml Communications.
PNEUMATIC DIFFERENTIATION*
By HERBERT F. WILLIAMS, M. D.
The article which first drew the attention of the profes-
sion to this process appeared in the " Medical Record " of
January 17th of the current year. It made no pretensions
to completeness, and was written with the hope that extend-
ed observation by competent men in the profession would
give to the subject treated its proper therapeutic position.
This process presents some facts so self-evident that
their discussion is idle. To deny all therapeutic value to
such an invocation of natural laws and forces would be ab-
surdity itself. On the other hand, the claims in its behalf
already made by overzeal are equally unwarrantable. There
is, therefore, a position in our therapeutics for pneumatic
differentiation.
While it can not be said that experience hitherto gained
has defined this position in all its relations, a few points
already demonstrated will be presented, in the hope that
their significance will provoke and encourage an inquiry
that can not fail of wholesome results.
The five patients with phthisis reported as recovered in
the original article remain in apparent health to-day, and,
with the exception of two treatments given in Case No. 1
for acute bronchitis, there has been no necessity to resume.
In Case No. 2 the patient has lost but one half-day from
his employment as machinist since his discharge from treat-
ment one year ago last March.
The subject of Case No. 5 has become a longshoreman,
does the work of a man in his position, and commands a
man's wages.
In Case No. 3 the patient remains at his employment in
perfect health.
In Case No. 4 the patient is the same as reported. The
slight drain from the fistulous opening in his side, how-
ever, prevents the rugged appearance of the other cases.f
On my first examination of this case, in which the prin-
cipal lesion was in the left lung, I found what I regarded
as primary changes taking place in the apex of the right.
The present immunity from disease in the latter locality has
suggested recent investigation of the other cases in which
the phthisical process was confined to one lung.
I find that in no instance has the sound lung become dis-
* Read, with a demonstration of the pneumatic cabinet, before the
American Climatolofrical Association, May 27, 1885.
•f These five patients continue in good health at the present time,
September 25th.
eased during the time of observation, and almost invariably
I have been able to watch the patients until death or a sub-
sidence of their symptoms. These observations, with their
inevitable conclusions, furnish, to my mind, arguments in
favor of a system of thorough antisepsis more suggestive
and cogent than any hitherto offered.
The six patients with primary infiltration remain in perfect
health with one exception. This patient, until two months
ago, had exceeded the best weight of his life. In his occu-
pation as solicitor he contracted a fresh cold, which ended,
as before, in consolidation. Treatment was resumed, and
Dr. De Watteville reports him rapidly improving.
In my investigations, formerly reported, I personally
conducted the treatment. Since then the immediate ad-
ministration has been in the hands of Dr. Fox in Brook-
lyn, and Dr. De Watteville and Dr. Tiegel in New York.
Their clinical experience in more than seventy-five cases
will doubtless be detailed by themselves.
They have, however, afforded me daily opportunity for
consultation and continued access to their memoranda.
Their courtesy enables me to make confident assurance
that in their practice "the relative results have been such as
to confirm and emphasize the deductions originally pub-
lished. Enough time has not elapsed to permit of exten-
sive exploration in advance of the points then indicated.
I have deemed it profitable to collate many considera-
tions which have been impressed upon me by the contem-
plation of this method and of the conditions in which it
may be either appropriate, inadvisable, or doubtful. Many
of the suggestions which I make in this connection have
neither novelty nor significance except such as old and well-
recognized material always assumes when brought into rela-
tion with original research in the same field.
It is suggestive of the value of the treatment that its
development is in line with, and depends upon, physiologi-
cal axioms. The continued use of this method will discover
all degrees of adaptability and every shade of fortunate
result.
If there is one thing known concerning pulmonary
phthisis, it is that well-directed treatment must be early.
It is a safe, though not necessarily a correct, conclusion
that, however careful may be the physical diagnosis, if we
get evidence of lobular infiltration the probability is that
more than one lobule is affected. If the ear detects a rale,
there are several too distant for recognition.
I have long since come to base my prognosis upon an
estimate of more trouble than I am able to detect. There
is a great deal of truth in what I have recently seen written
by an unprofessional pen : " Pure air is the life of the lung-
tissue ; irregularity in the supply is lung disease."
There may have been a time in our individual history
when a catarrhal concretion, lodged in a remote bronchus,
was the smoldering ember threatening a conflagration that
would have consumed us had not one fortunate cough ex-
pelled the obstruction and removed the contingent conges-
tion or infiltration. No one has a right to treat lightly the
simplest cough when appealed to for relief or advice. Fur-
ther back than this, if we, as physicians, are going to
change the statistics in pulmonary consumption, we must
Oct. 3, 1885.]
WILLIAMS: PNEUMATIC DIFFERENTIATION.
371
inculcate the well-known laws that are conducive to pul-
monary health, and demand of the heads of our families a
promise that they will compel their developing children to
breathe properly.
We come, then, to the earliest opportunity when the
benefits of this process may obtain. In childhood, when
inflammatory action is so liable to be set up and where its
consequences are so frequently overlooked on account of
the elastic vitality of youth, we have a field for action in
preventing the collapse of lobe and lobule and in removing
all tendencies to the retardation of proper circulation, which
not only produce immediate mischief, but may be, I be-
lieve, the cause of the easy development of the gravest symp-
toms in maturer life — as, for instance, the sudden haemor-
rhage, without the appearance of a symptom tbat occasioned
anxiety in the patient.
In the formative period of childhood and youth the
proper expansion of the lungs will do much to prevent the
pernicious consequences of improper frame development.
The questions of treating actually instituted disease of the
lung are too vast to comprehend in a single paper.
Thus far no patient able to apply for treatment has been
refused, though in many instances the patients and friends
have been told that temporary relief and improvement, if
any, were all that could be expected. Indeed, I feel that in
some cases of phthisis alleviation has been a greater achieve-
ment than recovery in others.
In any new form of treatmeut, and especially one as
radical as this, the early applicants are those who spend
most of their lives in seeking for that which they will never
find, and would not appreciate if they did — viz., restoration
to health. It has sometimes been difficult to exercise sound
judgment and impart proper advice on account of their ear-
nest solicitations. Such patients, if allowed, easily magnetize
themselves at first, and will construe the feelings that are
engendered by hope and novelty into actual improvement.
In all acute conditions such inspirations may be allow-
able, but the chronic cases demand the exercise of caution,
though at the risk of reproach for coldness and apathy.
Through the careful labors of Dr. Austin Flint, we have
been taught that there is a tendency to self-limitation in
the phthisical progress.
I recognize in some cases a cessation of the severity of
symptoms, and occasionally meet patients who profess to
have outlived by many years the prognostication of the
leaders in our profession.
So far as I know, no explanation has been offered for
i such conditions. I have questioned if further investigation
in the life-history of the Bacillus tuberculosis may not bear
a kindred relation to the germs of some of the eruptive fe-
i vers, where a thorough propagation renders the soil unfer-
tile for subsequent thrift.
In a case under this treatment when, if I may so speak,
| the crisis has not been reached, every form of encourage-
1 ment is permissible ; but we meet some patients who have
! surprised everybody by recuperation, whose early gratitude
I has been succeeded, first, by two or three years of chronic
I process, then by growing unthankfulness, and finally by
despair. They are quick to seek new devices, adopt strange
methods, or grasp without discernment for anything or
everything that promises well. When such a person ap-
plies to me he will have the benefit of my experience,
which says that relief and improvement are all that can be
expected.
To find a solution for this we have but to look at our
post-mortem records, where fatty livers and hearts, or ob-
literation of the kidney cortex, with its frequent cysts and
adherent capsule, plainly point to concurrent or dependent
degenerative action. Where pyogenic cavities have guarded
the system from frequent pyaemias, or where, from any
cause, secondary assimilative or organic changes have not
taken place, even though the patient may have suffered for
years, I doubt not that permanent improvement or recovery
may be expected.
It is to the treatment of these chronic cases that my re-
marks in the closing paragraphs of my first paper were
mainly addressed. Good judgment suggests that rest and
quiet are more applicable to some cases than ill-advised at-
tempts at recovery, especially those that demand over-exer-
tion in the patient. Still, such cases have been and must
be met, and, with the nicety of graduation of pressure to-
gether with the influence of remedial or perhaps nutritive
agents, and the certainty with which they can be introduced
into the general circulation through the lungs, an improve-
ment can be made upon what has thus far been accom-
plished by this process.
There is a great scope for discrimination not only in
regard to the selection and administration of remedies in
this manner, but also as to the force calculated to produce
the best results. I have seen how unfortunate results may
be ascribed to this process with which it may have nothing
to do.
The irregularity of the symptoms that develop in the
progress of phthisis is such that it is often difficult, if not
impossible, to determine whether untoward developments
are a morbid incident or the result of therapeutic error.
The subject for earliest study was that which seems at
first to trouble every investigator with whom I have con-
versed— viz. : The effect on the pulmonary circulation with
reference to production or arrest of haemorrhage.
All seem to have an exaggerated idea of the force best
calculated to produce good, and, with a fear born only of
unfamiliarity, shudder at the possibilities of calamity.
It is possible that the coincidence of instant death upon
the first inspiration might arise ; or, through carelessness or
incapacity, too much power might be exerted, which would
act as a direct cause. Human fallibility is such that it mav
be impossible" to determine the existence of fatty-degener-
ated bronchia] walls, attenuated alveolar septa, or unpro-
tected or aneurysmal arteries or veins.
When the totality of the symptoms points to any or all
of these conditions, it is incumbeut on the operator to use
every possible precaution. But, when such precaution is
observed, I claim for the procedure the protection accorded
any measure adopted for the administration of potent agents.
Exceptional disaster could not forbid intelligent use.
It would be as just to return to primeval modes of travel
through fear of railroad mismanagement. It is no argument
372
WILLIAMS: PNEUMATIC DIFFERENTIATION.
[N. Y. Med. Jock.,
against the therapeutic value of ^-grain doses of arsenlous
acid that two or three grains may kill.
Originators in surgical procedure have outlived the ob-
loquy of initial failure.
Chloroform is fatal as well as beneficent. But to those
who are forward in their estimation of the dangers of this
process I am indebted for valuable argument in its favor.
It must be granted that the force is constant, for it is natu-
ral. An agent for harm may be made an agent for good
when applied to suitable conditions, and its very malignity,
when unrestrained, is an incentive to harness it for human
welfare.
The healing art would be tame and loathsome if emascu-
lated of every capacity for peril.
In the discussion following the very able paper read be-
fore the New York Academy of Medicine by Dr. E. D.
Hudson, Jr., " On the Physical Examination of Weak Chests
and Differential Diagnosis of the Several Forms of Early
Phthisis," Dr. Loomis is reported as saying that " he had
been able more than once to recognize the presence of acute
phthisis a number of weeks before the hemorrhage oc-
curred which ushered it in, and by means of the peculiar
harsh quality of the respiratory sounds." My confidence
in the preventive power of this process, together with the
influence of an appropriate astringent, in this manner ap-
plied, is such that, should my lungs be judged by him to
be in this condition, I should at once resort to this treat-
ment to forestall such calamity.
In my first paper I spoke of the way in which the capil-
lary circulation of the lungs was reduced by this means —
namely, by decreasing the resistance of the blood in its pas-
sage through the lungs by the fuller inspiratory and expira-
tory effort. If it was my intention to obtain the direct
haemostatic effect, I should do what is always done when
we cau — in other conditions of haemorrhage — apply pressure.
The distribution of the circulating vessels of the air-cells
and ultimate bronchi is such that, if a continued inflation
can be maintained in them, exsanguination of their walls
must take place. It is possible to accomplish this by a
slow, full inspiratory act under any pressure thought de-
sirable, maintaining this as long as can be with comfort. The
expiration must not be made against the external air, but
into the cabinet, and, as soon as possible, a full inspiration
must again be made.
Such explanation might seem inadequate, but I think will
be strengthened when I say that I have never seen haemor-
rhage accompanying or immediately following treatment.
In each of six cases a single seizure has occurred at in-
tervals of from twenty-four hours to several days after the
last treatment, This did not interfere with the progress of
treatment.
In another case, characterized for three or four years
before treatment by at least annual haemorrhages, the pa-
tient sustained with complete immunity thirty one treat-
ments covering the month in which he had come to expect
the recurrence of his trouble, had gained two pounds and
a half, and was subjectively improved, when he was over-
taken by a haemorrhage which rendered further treatment
inadvisable. I
We need not speak in detail of the acute conditions in '
which theory and practice have demonstrated the great util-
ity of this process. As clinical evidence is gained we can I
more accurately anticipate the probable result of treatment
in given cases. The conditions under which remedial and,
perhaps, nutritive agents can be administered are such that
an improvement upon previous attempts at this method can I
be expected.
In the pre-tubercular stage, when imperfect nutrition
and assimilation are the first indications of impending dis-
ease, much may be hoped for from this form of medication. I
From experiments recently made, I think it a close approxi- *
mation to say that from ten to fifteen per cent, of the atom-
ized solution can be condensed upon the respiratory area.
In the treatment of emphysematous conditions great benefit
has been produced in three cases. This is paradoxical, for
at first sight it would seem that to expand residual air
would of necessity stretch its enveloping membrane and,
of course, aggravate the condition.
The forces that produce emphysema are largely expira-
tory. In my first paper it was shown to be impossible, by
any judicious resort to the force at our command, to pro-
duce over-distension. The improvement that has followed
the treatment of emphysematous conditions is undoubtedly
due to the subsequent increased circulation of the blood in
the diseased part, and the consequent improvement in the
tonicity of the alveolar walls due to improved nutrition. It
may be also due to the removal of excess of catarrhal secre-
tions in the ultimate bronchi or any anterior point. Mr.
Ketchum has completed a device by which alternate rare-
faction and compression of air can be made synchronously
with the respiratory act, or by which either compression or ,
rarefaction can be maintained at the will of the operator.
This will enable us to obtain all the results of the com-
pressed air-bath with which we are familiar, and to which
our attention has recently been called by the lectures of
Dr. C. Theodore Williams, of England, and by the methods
well known throughout the Continent.
I am indebted to Dr. Teigel and Dr. De Watteville for
the following report of cases occurring in their practice :
W. P. M. ; occupation, barber ; presented himself for ex-
amination April 18, 1885; age, twenty-seven years; colored.
Best weight, 132 ; present weight, 120'. Temperature, 101-102°.
Expansion, two inches.
Condition. — Married ; no children.
Family History. — On father's side, mulattoes; on mother's
side, octoroons. Family history, negative.
Personal History. — A little over eighteen months ago he
caught cold and could not get rid of it. He got weaker and
weaker. Consulted Dr. Speir in Brooklyn; was told that his
lungs were very weak, and was sent to the country. There he
received great benefit, and returned, he thought, a well man.
He soon fell hack, however, and got very much worse. Heavy ,
cough day and night. Complete loss of appetite ; never had
any pain, however. Last December coughed up quantities of
heavy fetid yellow matter. He does not expectorate much,
but has a dry cough, which gives him no rest. He is losing
flesh, has fever every night up to 102°, and is extremely short
of breath.
Inspection. — A poorly developed thorax with insufficient ex
pansiou. Body emaciated. On both sides the thorax is flat
Oct. 8, 188o. |
WILLI A MS : PNEUMATIC DIFFERENTIATION.
373
toned below the clavicles, amounting on the right side to a
positive excavation.
Palpation — Thorax resists pressure and is not normally
elastic, especially on upper half. Vocal fremitus much in-
creased, especially on right side.
Percussion. — -Dullness and high-pitched note oa right side in
clavicular and supra-mammary region. Less marked on left.
On right side the sound is tympanitic, and changes character
and pitch when mouth is opened or shut. With open mouth it
gives a typical cracked-pot sound. This tympanitic percussion
note is limited to a space the size of a hen's egg. Percussion
sound improves as we approach the middle third. On left side
it is better than on right.
Auscultation. — On right side, in clavicular region, cavernous
breathing, but not accompanied by gurgling. Vocal resonance
much increased in upper third. Breathing tubular. Expiration
saccadent and prolonged. Rales of every description — loud,
sonorous, and sibilant — are heard in very low breathing ; fine
crepitant rales are observed. They diminish as we descend the
thorax, and are infrequent on lower half. On left side very
much the same condition exists, though not in the same degree.
Dry rales are heard in front and back, but diminish gradually
till they nearly cease at the base.
Course of Treatment. — Three times weekly. Began on April
18th. Commenced with T\ inch and a spray of a solution of
1 per cent, amnion, chlorid., 5 per cent, glycerin.
April 25th. — Increased to j% inch. He breathes nicely, but
his respirations are limited. He reports that he sleeps well at
night, and that his appetite improves. He has expectorated a
great deal.
May 1st. — Respiratory sounds are stronger, but rales still
present in great number. The objective signs are very little
changed. Subjectively, patient is in high spirits. He eats vo-
raciously, has a normal temperature even at night, coughs dur-
ing day, and expectorates heavily. He feels " splendid."
6th. — Changed to red-bark decoction (made by Mr. Beudiner,
Tenth Street and Third Avenue).
12th. — Caught cold during damp days, and developed catarrh
on left side. Coughs much, and does not look so well.
27th. — Marked progress. Patient has gained strength, so
that he was able to assist and officiate himself in house-moving,
going up and down stairs frequently. Feels none the worse for
it. The left lung has recovered. On right side the rales have
much diminished. On left side the improvement is marked,
with exception of the region of the clavicle ; the rales have
nearly disappeared ; here and there fine crepitant rales are
heard still. The expansion is limited still, but has increased
about half an inch.
The breathing in clavicular region has changed in character,
the note being higher and the character more tubular than cav-
ernous. Percussion, however, still shows the former symptoms,
although the space whero the cracked-pot sound is heard seems to
be more limited. Subjectively, the patient's account of himself
leaves nothing to desire. He coughs still, but only when he
gets rid of mucus. Sleep is good, appetite good. Temperature
normal. Strength improved, but by no means great. Talks of
returning to work soon. He takes treatment with great regu-
larity three times weekly, and intends continuing for some
time.
M. O., aged thirty-six years, married; one child, which died
of hydrocephalus and spina bifida. Patient presented himself
for examination on March 28, 1885.
Family History. — On paternal side, negative; on maternal
side, frequent throat troubles. One brother died four months
ago of tubercular laryngitis and pulmonary phthisis.
Personal History. — Patient has for many years suffered from
catarrhs, cough, and light attacks of pleuritic pains. Since
New Year's the cough has much increased, often producing
broken sleep, loss of appetite, and a general tired feeling; short
breath on the least exertion. A dull soreness, accompanied some-
times with sharp, stitchy pains on left side, on the back, under
the lower half of scapula; also on right side in the mammary
region, between the fourth and sixth ribs, accompanied by
wheezing at intervals. He feels feverish at night, and has to
take quinine frequently. His occupation (broker) exposes him
to draughts and constant changes of temperature. He is losing
fiesh.
Inspection. — A tall man, not very well nourished, with an
extremely long and narrow thorax. Complexion pasty and
pale ; lower eyelids baggy ; voice slightly hoarse. Hands long,
clammy, and finger-nails thin, round, and bent forward extreme-
ly. Respiration jerky and quick, especially on least exertion.
Respiratory movements extremely limited and chiefly abdomi-
nal. Full expansion at mammary line not quite two inches.
Palpation. — Respiratory fremitus exaggerated on right side
in front, also on left side under scapula. Apex-beat of heart
normal.
Percussion. — Dullness and high-pitched note, but not ex-
treme, on the upper two thirds of right lung in front. Left side,
normal resonance, except in the scapular region.
Auscultation. — Right side front, saccadent breathing and
prolonged expiration ; character vesicular. Fine crepitant rales
are heard as far as the sixth rib, and very slightly in the clavi-
cular region. In the region of nipple, fine sibilant r&les at end
of inspiration and during expiration. Respiratory sounds, on
the whole, are feeble. On left side front the sounds are more
normal. Behind, under scapula, loud sonorous and sibilant
rales; also fine crepitant rales, especially during expiration.
Course of Treatment. — March 28th, three times weekly,
HgCl2 yoVir to tot with T3r inch. Breathes with difficulty, and
very jerky.
April 3d. — Complains of more pain under scapula.
8th. — Increased to inch.
11th. — Varied with inhalation of iodine.
20th. — Increased treatment to six times weekly. Tried de-
coction of red bark containing four and a half per cent, cinchona
red (tannin).
30th. — Patient is much improved; breathes easily and fully
against Ts„ inch ; rales nearly gone; pains gone.
May 3d. — Got his stomach out of order and got cold (neg-
lected precautions). Sibilant rales appearing again, but with
considerable expectoration.
6th. — Rales entirely gone. Pain has completely left.
10th. — Reduced to three times weekly ; continue steadily
with red-hark decoction.
27th. — Patient has not turned up for treatment for over a
week. On last examination the objective signs were gone, as
far as auscultation showed it. He is looking much better;
sleeps well at night; his appetite good, at least fair; coughs a
little in the morning, but not during the day. He is still a little
short-breathed, but nothing like before. He should have con-
tinued for a few weeks longer, but his business, he said, called
him away.
DISCUSSION.
The President had seen the patient to whom the author re-
ferred as having had a hemorrhage within twenty-four hours
after a treatment. The patient bad had thirty-one treatments
and the hasmorrhage occurred after the thirty-first, lie bad
been under Dr. Loomis's care for four years, had, ho believed
spent one year in the Adirondack's, and had supposed that he
had entirely recovered. At any rate, he went back to his work
as a lawyer, promising to spend four months in the Adirondaeks
37±
FOWLER: HYDRONAPHTHOL ; A NEW ANTISEPTIC.
[N. Y. Med. Jour.,
every year. It was not necessary to mention all the physical
signs which had been present ; there had been well-advanced
phthisis on the left side near the apex. He did not go to the
Adirondacks, but to the Berkshire Hills, last summer. Dr.
Loomis had not heard of him for more than a year and a half,
when he was called to visit him two or three months ago while
having a very profuse haemorrhage, which had gone on for a
number of days. He said that he had had the treatment ac-
cording to Dr. Williams's method a great many times, but that
the last time he thought there was a little carelessness in the
manipulation. At least he attributed the haemorrhage which
occurred to that. The patient did not think the treatment was
dangerous if it was properly administered. The haemorrhage
continued for three or four weeks. That was the only case Dr.
Loomis knew of in which haemorrhage had occurred in connec-
tion with this treatment.
Dr. Williams had one or two other patients who were doing
well. One, a lady, had done very well under this special treat-
ment. She had a cavity in the lung, and had been the world
over for her health. She had remained at home the past win-
ter, and was much better than in the autumn.
Dr. Armor, of Brooklyn, had been interested in the treat-
ment and views of Dr. Williams, and had kept under observa-
tion some patients so treated. He thought the matter could be
6tated in a few propositions, some of which might have to be
considered hereafter : First, the benefit of the expansion of the
lungs by the apparatus without reference to the local medica-
tion. Second, the question as to whether antiseptics and other
agents could be introduced more deeply into the lung substance
by this means than by any other device which had been pro-
posed. Third, the practical result, which was to be tested by
clinical observation. He was aware that an instrument of this
kind should be in the hands of careful observers, who were
capable of diagnosticating their cases and of appreciating the
results. It might be a dangerous instrument in the hands of
others. He thought it should be most carefully guarded by most
careful men. One case had recently come under his observa-
tion in which he had been very much interested. He carefully
examined the young man before he was submitted to treatment.
When he came to Dr. Williams's office he was so weak and ema-
ciated that he had to ride in a carriage. It looked to him like a
very unpromising case. He had a few weeks before an attack
of pneumonia, probably on the right side. Dr. Armor found
the patient, as stated, very much emaciated, feeble, rapid pulse,
feeble expansion of the lung on the right side ; below the
scapula were marked dullness, entire absence of respiratory
murmur, and above rales. It looked like a case of unre-
solved pneumonia. On submitting the patient to a treatment,
the lips looked redder and a good deal of expansion of the lungs
took place. He did not see the young man again for about a
month. Dr. Williams told him that after a few days' treatment
there began to be moist rales in the lower portion of the right
lung and quite free expectoration. Dr. Armor found at his last
examination still slight dullness below the scapula over the re-
gion referred to, but much less than formerly ; there was respi-
ratory murmur all over that portion of the lung, but a little
feebler than on the other side ; there were no moist rales. The
symptoms had entirely abated ; there was absence of fever, the
general appearance was good, the appetite good ; he had gained
about a pound a week, and bad walked a distance of two miles
to his office. There was certainty a very remarkable improve-
ment in the condition of the lung, whether it was due to con-
stitutional treatment or to the instrument. He had had thirty-
one treatments. In a letter to him, Dr. Bowditch, of Boston,
had said it was his impression that this treatment would mark
a new era in the management of pulmonary affections.
HYDRONAPHTHOL ;
A NEW ANTISEPTIC.
By GEORGE R. FOWLER, M. D.,
SURGEON TO ST. MARY'S GENERAL HOSPITAL, BROOKLYN.
Hydronaphthol, the subject of the present article, has
only recently been discovered, and this is believed to be
its first introduction into surgical practice. It was in the
belief that it would be found of value in the treatment of
wounds that I began the investigation of its antiseptic prop-
erties in the early part of the present month, when my at-
tention was called to the compound by Mr. W. J. Rigney,
of New York, to whom I am indebted for the facts regard-
ing its composition herewith presented.
Hydronaphthol belongs to the phenol series, and bears
the same relation to naphthyl, the hypothetical compound
radical of naphthalin, that carbolic acid does to the com-
pound radical phenyl. Thus, carbolic acid was formerly
regarded as the hydrated oxide of phenyl. Hydronaphthol,
considered in the same way, would be a hydrated oxide of
naphthyl. The following formula will show the analogy :
Carbolic acid, C]:iH50, HO ;
Phenyl, CI2II5
Hydronaphthol, C50H7O, HO ;
Naphthyl, C20H7
At the present time, however, these hypothetical com-
pounds, phenyl and naphthyl, are considered as being obso-
lete, and not capable of existing. In fact, carbolic acid is
regarded as an oxide of benzol, or as a benzol in which one
of the hydrogens is substituted by one hydroxyl (O H).
According to the graphic formula of Prof. Kekule, this
substitution occurs as follows :
H
i
C
^ \
H-C C-H
i ii
H-C C-H
\ /
C
i
H
H
i
C
H-C^ C-O-H
H-C C-H
% /
C
i
H
Benzol. Carbolic Acid.
In the aromatic hydrocarbons are found many isomeri-
cal substances. This peculiar identity in chemical com-
position, associated with varying physical properties, can
only be accounted for by a difference existing in the arrange-
ment of the atoms in the molecule. The graphic formula
as above illustrated is well adapted for explaining the rela-
tions and properties of these aromatic compounds, of which
benzol is the prototype. Thus, in all the monosubstitutions
of benzol there is but one compound possible ; no matter
in what position the substitution takes place, the product
must be the same. As seen in the preceding formula (car-
bolic acid), the hydroxyl (O H) substitution takes place in
the first position, but the product would be the same if it
were to take place in any of the other five positions. While
this is true of the monosubstitutions of benzol, the disub-
stitutions are capable of forming three different compounds,
identical in chemical composition but very different in their
physical properties.
Oct. 3, 1KM5.)
MACKENZIE: ISOLATION OF THE TEMPERATURE SENSE.
375
A knowledge of the relation, constitution, and proper-
ties of these substances is indispensable to an intelligent
appreciation of their usefulness and application ; and, as all
the so-called phenols possess, in a greater or less degree,
antiseptic properties upon which their value in surgical
science as well as preventive medicine depends, I may be
pardoned for thus alluding to some recently developed facts
in their chemistry, in this connection.
Naphthols are the hydroxyl substitutions of naphthalin,
and are two in number, commonly known as Alpha- and
Beta-naphthol. These are made by heating naphthalin with
sulphuric acid. Alpha-naphthol is formed when 60° to 90°
C. is reached, and Beta-naphthol at from 180° to 190° C.
The Alpha- or Beta-naphthalin-monosulphonic acid thus
formed is treated with sodium hydrate, and is decomposed
into sodium naphtholate, sodium hydrate, and sodium sul-
phite. Naphthol is obtained from the sodium naphtholate
by decomposing it with hydrochloric or sulphuric acid ; it
is then purified by distillation.
Hydronaphthol is a derivative of the hydroxyl substitu-
tion of naphthalin, which latter of itself possesses antiseptic
properties of sufficient value to have already excited no-
tice and a desire to learn more of its compounds. The
term " hydronaphthol," although perhaps not, strictly
speaking, correct, yet conveys sufficiently well its character
and relations to naphthalin, and at the same time is a con-
venient term for every-day use. It has been but recently
discovered that it possesses antiseptic properties, and the
claim is made that it is from ten to fifteen times more effi-
cient than carbolic acid. It is the most promising antiseptic
of the phenol series, and, besides, possesses so many other
advantages over substances now used for this purpose that
it bids fair to supersede many of these. In surgical prac-
tice it will take the place, probably, of carbolic acid. Of
the many new members of the phenol series which have
been discovered since Calvert called attention to carbolic
acid about thirty years ago, and which have been utilized
in the industrial arts, some are better antiseptics than the
latter. With but one or two exceptions, however, none
have obtained any prominence as germicidal agents. Car-
bolic acid, though a fairly reliable antiseptic in strong solu-
tions, when so used, involves some risk to life, from its cor-
rosive action upon animal tissues and well-known poisonous
properties. In weak solutions it is exceedingly unreliable,
and its disagreeable odor often hides that of putrefaction,
instead of preventing the occurrence of the latter. On the
other hand, hydronaphthol is non-irritant, non-poisonous,
and non-corrosive ; and, although only soluble in water to
the extent of one part in one thousand, in this proportion
is antiseptic. It has no odor to disguise that of putrefac-
tion, nor is it decomposed or rendered inert by the products
of putrefactive decomposition — such as sulphureted hydro-
gen, ammonia, etc. It is far more stable than carbolic acid,
not being volatile at ordinary temperature. Its vapor, when
volatilized for purposes of fumigation, has no obnoxious
effect upon the organs of respiration. It will not injure,
either in substance, solution, or vapor, colors or tex-
tile fabrics. Its sparing solubility in water is rather
an advantage than otherwise, as mistakes in making solu-
tions can not occur. A saturated solution is about of the
strength of one to one thousand, and in this proportion it
will perfectly preserve for an indefinite time animal tissues
and fluids, and yet upon living tissues this solution produces
no perceptible effect other than the formation of a very
slight albuminate film — this latter to be considered rather
an advantage than otherwise, inasmuch as it constitutes
an additional security against infectious germs floating in
the air. If for no other reason than that it is non-corro-
sive, and hence will not injure the polished surface and
keen edge of cutting instruments, it is to be preferred to
mercuric bichloride, and to the latter it is second only in
antiseptic qualities. It has a slight aromatic taste and odor,
and crystallizes in scale-like clinorhomboid lamina? of a sil-
very white or grayish hue. Although but sparingly soluble
in water, it dissolves freely in alcohol, ether, chloroform,
glycerin, benzole, and the fixed oils. It is not volatile at
ordinary temperature, but begins to sublime at about 90° C.
With the alkalies and the alkaline earths it forms com-
pounds which are unstable, are readily decomposed by car-
bonic acid, and of doubtful antiseptic value. It is easily
powdered, and in this condition, triturated with carbonate
of magnesia, silicates, such as fuller's earth, China clay,
etc., in the proportion of two parts of the hydronaphthol to
one hundred of either of the above named, can be dusted
along the line of incision and over the mouths of drainage-
tubes, in the latter application having an advantage over
iodoform, now so commonly used for that purpose, in that
it does not dry up the serum escaping from the wound cav-
ity, and thus block up the exit extremity of the tube. Ab-
sorbent gauze, cotton, jute, wood-flour, sawdust, peat, moss,
and paper-wool may be impregnated with it by immersing
them in its alcoholic or benzole solution and then drying ?
the hydronaphthol crystals cling to these without the aid of
stearin, paraffin, or resin, as in the case of carbolic acid.
As it is not decomposed by the presence of organic matter,
it possesses this advantage over corrosive sublimate in the
preparation of surgical dressings. Its ten-per-cent. alcoholic
solution perfectly sterilizes silk, and sufficiently hardens
and preserves, as well as sterilizes, catgut.
(To be continued.)
ISOLATION OF THE TEMPERATURE SENSE
IN THE ORO-PHARYNGEAL CAVITIES
AND NASAL PASSAGES BY MEANS OF
COCAINE*
By JOHN N. MACKENZIE, M. D.,
BALTIMORE.
My atteution was first called to the isolation of the
temperature sense by means of cocaine through an observa-
tion of Dr. William Warfield, of this city, Avho noticed dur-
ing an operation on the eye (under the anaesthetic influence
of this drug), performed by Dr. Russell Murdoch, that, while
the sensibility of the conjunctiva and cornea was abolished,
the contact of the instruments was felt as a distinctly cold
* Read by title before the American Laiyngological Association,
June 26, 1885. See also letter in (Philadelphia) "Medical News," May
I 30, 1885, on "Isolation of Temperature Sense."
376
IVES: A CASE OF SUBMUCOUS LARYNGEAL EMMORTiEAQE. (N. Y. Mbd. Jouk.,
sensation. Subsequently Mr. H. H. Donaldson, of the
Johns Hopkins University, acting upon this hint, examined
the eyes of two patients with reference to this singular fact,
and discovered that, although the eye was rendered com-
pletely insensitive, the sensations of heat and cold were
readily distinguished.
Struck with the original observation of Dr. Warfield, I
experimented with regard to the isolation of the tempera-
ture sense in the nasal and oro-pharyngeal cavities. Six
persons (hospital patients) were taken for the experiments.
Having thoroughly anaesthetized the mucous surfaces of the
soft palate, uvula, and nasal passages with a four-per-cent.
solution of cocaine, a probe, which had been previously
immersed in a mixture of ice and salt, was made to impinge
upon the parts rendered insensible to contact and pain. A
distinct sensation of cold was complained of in each in-
stance. The opposite extremity of the same probe was
then heated over the burner of a lamp used for laryngo-
scopy purposes, and in its heated condition carried over
the anaesthetized area. While absolutely no pain was felt
by any of those experimented upon, there was a marked
unanimity of the answers, given voluntarily, in regard to
the sensation of heat. In three of the cases an eschar fol-
lowed the application of the heated probe, and in one an
acute pharyngitis developed; yet at the time of application
no pain was felt, though the temperature sense remained
intact. These observations are of interest, in view of the
fact that, while recent physiological research has rendered
it probable that the sensations of heat and cold are distinct
from those of mere contact and pain, it has heretofore been
impossible to demonstrate the fact by the complete isolation
of the temperature sense. It is accordingly obvious that its
separation from the other senses may lead the way to more
interesting physiological discovery.
A CASE OF
SUBMUCOUS LARYNGEAL HEMORRHAGE
COMPLICATED WITH CYST*
By FRANK L. IVES, M. D.
Having been unable, after careful search, to find among
the few recorded cases of cyst of the vocal bands anything
resembling the following, it has seemed to me worth while
to present it to your notice :
A robust man, about forty years of age, whom I had previ-
ously treated for a slight catarrhal affection of the larynx, called
upon me on April 25th and gave the following history: The
night before he had exerted his voice to an unusual degree at a
public meeting. He felt no inconvenience after returning to his
home, but, on waking the next morning, at first had great diffi-
culty in making himself heard. Afterward his voice grew a trifle
clearer. He had no pain or soreness in his throat, nor had he
any difficulty in breathing. The only sensation was one of irri-
tation, which caused him to "hack" almost continually. When
be came to me he could only speak in a hoarse whisper. Exam-
ining his larynx, I found it to be normal in shape and color, ex-
cept the left vocal cord, which was swollen uniformly through-
out its entire length to about twice its natural size, and was a
* Read before the American Laryngologieal Association, June 25
1885.
bright red in color, the coloring being perfectly even. My pa-
tient being forced to leave that evening, I directed him to use a
soothing inhalation, and use his voice as little as possible. On
May 2d he called upon me and stated that his voice had im-
proved somewhat, but the irritation still remained. Examina-
tion showed the left cord to have returned to its normal size,
and to he only slightly congested, but upon the edge and near
the middle there was a smooth, glistening tumor, of about the
size of a pea and light brown in color. It was not pedunculated,
and its origin seemed to be merged in the substance of the cord.
On touching it with a probe it was easily indented, but quickly
returned to its original shape. Being convinced, from the ap-
pearance of the growth, that it was a cyst with sero-sanguineous
contents, I proposed to my patient to make an incision into the
growth, but also told him that the growth would disappear
without any operation — how soon, I could not say. He pre-
ferred to wait. Four days after he called upon me and stated
that the previous evening, while at dinner, he had a violent
paroxysm of coughing, caused by some food going the " wrong
way." When he recovered, he found to his delight that his
voice was perfectly clear. Examination showed the growth to
have disappeared.
Dock Dotites.
BOOKS AND PAMPHLETS RECEIVED.
A System of Obstetric Medicine and Surgery, Theoretical
and Clinical, for the Student and Practitioner. By Robert
Barnes, M. D., Obstetric Physician to St. George's Hospital,
Consulting Physician to the Chelsea Hospital for Women, etc.,
and Fancourt Barnes, M. D., Physician to the Royal Maternity,
Charity, and to the British Lying-in Hospital, etc. Illustrated
with Two Hundred and Thirty-one Wood-cuts. Philadelphia:
Lea Brothers & Co., 1885. Pp. xxiii-884.
A Practical Treatise on the Diseases of Children. By Alfred
Vogel, M. D., Professor of Clinical Medicine in the University
of Dorpat, Russia. Translated by II. Raphael, M. D., formerly
House Surgeon to Bellevue Hospital, Physician to the Eastern
Dispensary for the Diseases of Children, etc. Third American,
from the Eighth German, Edition. Illustrated by Six Litho-
graphic Plates. New York: D. Appleton & Company, 1885.
Pp. xii-640. [Price, cloth, $4.50 ; sheep, $5.50.]
Plumbing Problems ; or, Questions, Answers, and Descrip-
tions relating to House Drainage and Plumbing, from the " Sani-
tary Engineer." With One Hundred and Forty-six Illustrations.
New York : " The Sanitary Engineer," 1885. Pp. xiv-244. .
Practical Therapeutics: a Compendium of Selected Formulae
and Practical Hints on Treatment, Systematically Arranged, In-
terleaved, and copiously Indexed. By Edward J. Bermingham,
A. M., M. D., Fellow and ex- Vice-President of the American
Academy of Medicine, etc. New York : J. R. Bermingham,
1885. Pp. 6-420.
Transactions in the Texas State Medical Association, Seven-
teenth Annual Session, held at Houston, Texas, April 21, 22,
and 23, 1885. Austin, Texas : Printed for the Texas State
Medical Association. Pp. 1-430.
Consanguineous Marriages : their Effect upon Offspring.
By Charles F. Withington, M. D., of Roxbury. Read at the
Annual Meeting of the Massachusetts Medical Society, June 9,
1885.
United States Consular Reports. Supplementary Reports on
Cholera in Europe in 1884. Washington : Government Printing-
office, 1885. Pp. 1-12.
Oct. 3, 1885.]
LEADING ARTICLES.
377
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Pnblished by Edited by
D Appleton & Co. Prank P. Foster, M. D.
NEW YORK, SATURDAY, OCTOBER 3, 1885.
THE SURGEON-GENERALSHIP OF THE MARINE-HOSPITAL
SERVICE.
We lately took occasion to deprecate the efforts that, it was
alleged, were being made to induce the Administration to dis-
miss Dr. Hamilton from the office of Surgeon-General of the
Marine- Hospital Service, for it was evident that there were no
other grounds for those efforts than the yearnings of a horde of
office-seekers — so evident that we expressed our disbelief in the
probability of any such action being taken by the President or
the Secretary of the Treasury. Dr. Hamilton has not yet been
superseded, and we still hold to the conviction that the Admin-
istration would not finally have dismissed him, no matter what
pressure might have been brought to bear on it. Since the
article we have referred to was written, however, Dr. Hamilton
has tendered his resignation of the office, preferring, no doubt,
to take the initiative, as the matter had excited public atten-
tion. This~course on his part may be taken to be indicative of
a sensitiveness that is the natural accompaniment of those other
qualities that have made him so efficient and satisfactory an
officer ; but it does not in the slightest degree relieve the Ad-
ministration of its plain obligation not to allow of so flagrant
a violation of the spirit of civil-service reform as the superses-
sion of this officer, even by the acceptance of his resignation.
Dr. Hamilton is young, active, and enthusiastic in his work — a
work that to a great extent he himself has organized— and it
is not to be supposed that he is anxious to shift the burden of
his responsibilities to untried shoulders, and relapse into the
quiet of a subordinate position. His resignation is undoubtedly
due to the machinations we have spoken of, and our belief is
that the President will readily foresee the interpretation that
the friends of civil-service reform would put upon his accept-
ance of a resignation called forth by the circumstances of this
case. We are glad to be able to add that there are indications
that the resignation will not be accepted.
We have lately received a letter from a medical officer of
the Marine-Hospital Service, in which he thanks us for the edi-
torial article which we published on the subject in our issue
of September 19th, and goes on to say that he, as a Democrat,
can not but regret that Dr. Hamilton should feel compelled to
resign, during a democratic Administration, solely for political
reasons, when, by his continuance of the policy of the late
Surgeon-General Woodworth, the service was taken out of poli-
tics, and Democrats were enabled to enter it on their literary
and professional merits solely. He expresses his conviction
that there is not an officer in the corps so competent to admin-
ister its affairs as Dr. Hamilton, and that a political appoint-
ment would, by a single stroke, destroy the bright prospects of
the corps as a harmonious body of workers. Finally, he hopes
that we may find time and opportunity to urge Dr. Hamilton
to withdraw his resignation. We presume that Dr. Hamilton
could hardly be induced to take this course, except by the re-
quest of the President or the Secretary of the Treasury, and,
indeed, apart from his natural disinclination to do so, it seems
to us better that the responsibility should rest, as it now does,
solely upon the Administration. The President has given
abundant evidence of his desire to further the efficiency of the
public services, and we doubt not that, now that Dr. Hamil-
ton's resignation will soon bring this matter pointedly to his
notice, he will himself furnish the readiest solution of the diffi-
culty by declining to countenance the sacrifice of the best in-
terests of the Marine-Hospital Service to those of the spoils
system.
MINOR PARAGRAPHS.
THE ANTI-VACCINATION FEELING IN MONTREAL.
A disposition to make the best use of the gifts sent by the
gods can not be said to have been strikingly exemplified of late
by a considerable portion of the people of Montreal. Indeed,
they seem rather to have taken pleasure in ranging themselves
with those conservatives of whom it was said in "The New
Gospel of Peace " that when they had fallen into hot water
they would suffer no man to pluck them out, lest they should
be scalded. It has been almost inconceivable to the great ma-
jority of the people of this continent that so enlightened a city
as the Canadian metropolis should for years have been the scene
of the only considerable opposition to vaccination that has
shown itself in America since the practice was established.
There is, to be sure, a wide-spread feeling that it would be un-
wise to make vaccination generally compulsory, as is done in
many European countries, but it would be difficult to find a
community in the United States that would offer any serious op-
position to temporary compulsion during the prevalence of a
small-pox epidemic. Such an opposition has been manifested in
Montreal for many years past, and in consequence the city has
suffered severely from small-pox at short intervals.
During the past week actual rioting has taken place, and
both the sanitary and the police authorities seem to have been
sadly unprepared for it. Physicians and members of the Board
of Health have suffered violence, and even a poor apothecary,
whose sole offense was that of including vaccine virus among
the commodities that he kept for sale, has had a like experience.
The anti-vaccination bigotry is said to be mostly confined to the
French Roman Catholics. If this is the case, it would seem to
be nursed more as a pretext for a war of races and of creeds
than from any traditional or inherited prejudices, for we have
never supposed that the Church of Rome was opposed to vac-
cination, and certainly the French as a nation have been unsur-
passed in its maintenance. It is curious to observe that the
French-Canadian anti-vaccinationists seem bent upon upholding
two somewhat remarkable allegations — first, that during the
present epidemic the French have not been stricken with the
disease in greater proportion than the English, and second, that
small-pox is rather a good thing to have. Meantime, the trade
interests of Montreal are suffering severely.
THE AMERICAN GYNAECOLOGICAL SOCIETY.
In this issue we conclude our report of the tenth annual
meeting of the society, which was held in Washington last week.
The proceedings are certainly to be ranked w ith those of the
378
MINOR PA RAG RAPES.
[N. Y. Med. Joue.,
most successful meetings that the society has ever held, and we
shall he much surprised if the sale of the tenth volume of the
"Transactions" does not show a continuation of the increase
of the demand for the series that has been apparent during the
past two or three years. Much of the success of any given
meeting of such a society depends upon those of the members
who reside in the city where it is held, and upon the extent to
which they succeed in enlisting the co-operation of the local
profession. Taking this view of the matter, we can not too
highly praise the Washington members, who, together with a
great number of the leading physicians of that city, exerted
themselves most effectively to make the meeting and the occa-
sion satisfactory and enjoyable. We understand that but four
members of the Washington Obstetrical and Gynaecological So-
ciety were absent from the dinner which that organization gave
to the fellows of the American Gynaecological Society, and that
those four were either sick or absent from Washington. In
view of the membership to which this young society has already
attained, the fact is not a little remarkable, and it affords a
striking proof of the zeal with which the obstetricians and
gynaecologists of Washington entered into the spirit of the occa-
sion. We trust that, as Dr. Busey suggested in his address of
welcome, the American Gynaecological Society will not allow
another decade to pass before it again chooses Washington as
its place of meeting.
A MEDICAL MISSION.
Usually our Government is averse to spending money for
scientific purposes, and it must be confessed that the underlying
theory of our Constitution rather calls for that sort of policy.
It seems sometimes, however, that there is too little disposition
to yield the theoretical point before the pressure of an urgent
need of scientific information of a nature to lead directly to
results of the greatest practical importance to the whole peo-
ple. It is pleasant to be able to record exceptions to this tradi-
tional inertia, especially of the sort mentioned in our news col-
umns— that, namely, of the appointment of Dr. Shakespeare, of
Philadelphia, as a commissioner to visit the scenes of cholera
prevalence in Europe, for the purpose of studying the disease
and the methods resorted to for controlling its ravages. No
more important subject could engage the attention of the Gov-
ernment at the present time, and it would be difficult to find a
man better qualified than Dr. Shakespeare to carry on the in-
quiry.
THE BROOKLYN PATHOLOGICAL SOCIETY.
In another column we publish the programme for the meet-
ings of this society, from October 8, 1885, to June 10, 1886. It
will be seen that the list of authors is made up of the names of
gentlemen who are widely and favorably known for their pre-
vious contributions, and that the subjects upon which they are
to read papers relate to a very wide range of the subdivisions of
medical science. These formal papers constitute, of course,
only one element of the work with which the society will be
occupied during the season, but in themselves they will form an
achievement that any such society might well be proud of. The
fact that the whole list could be made out before the society
season had begun betokens the society's continued activity, but
our readers, who have had its proceedings laid before them for
the past year or more, need no such proof of its efficiency.
NEWS ITEMS, ETC.
The Montreal Small-pox Epidemic shows rather an in-
crease Than any diminution. There were fifty -six deaths in the
city and its suburbs on Sunday, seventy-nine on Monday, and
eighty-four before four o'clock on Tuesday. It is gratifying to
learn that some at least of the Roman Catholic clergy have ad-
vised the members of their congregations to submit to vaccina-
tion, and that the Sisters of Providence are doing still greater
service by reporting cases of the disease to the Board of Health.
The sanitary officials of the city are reported to have asked the
New York Health Department to send one or more of their
attaches to Montreal, to assist in the organization of a plan of
managing the epidemic, but it is stated that our Commissioners
have concluded that it would be unwise to grant the request.
The latest estimate gives the number of cases now in progress
as between three thousand and thirty-five hundred.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending September 29, 1885 :
DISEASES.
Week ending Sept. 22.
Week ending Sept. 29.
Cases.
Deaths.
Cases.
Deaths.
Typhoid fever
59
13
39
16
Scarlet fever
15
1
15
2
Cerebro-spinal meningitis. . . .
4
5
2
2
4
2
4
0
46
30
39
19
2
2
3
3
A Vaccination Riot broke out in Montreal on Monday, the
occasion of which was the passage of an ordinance by the Pro-
vincial Board of Health making vaccination compulsory. The
house of a health officer, Dr. Laberge, was stoned, and the
Board of Health's central office was then attacked, and several
women among the applicants for vaccination are said to have
been struck with the missiles. After threatening a newspaper-
office and making sundry other demonstrations, the mob visited
the houses of Dr. Lachappelle, of the Board of Health; Dr.
Laporte, a public vaccinator ; M. Grenier, a public official ; and
the shop of an apothecary who sold vaccine virus. At each of
these places violence was displayed, and Dr. Laporte's bouse
was set on fire. A renewal of the rioting on the following day
seems only to have been prevented by a prompt and overwhelm-
ing display of military force.
The Cholera in Europe.— Dr. Edward 0. Shakespeare, of
Philadelphia, has been appointed United States Commissioner
to investigate the cholera in Europe, with special reference to
the recent outbreak in Spain. He sails next week with carte
olanche from the Government, and will be absent about three
months.
The Health of Foreign Cities.— We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office since
the date of the last bulletin, September 23d: Montreal, Canada.
— For the week ending September 23d : 235 deaths from small-
pox. No report of the number of cases. From September
21st to 23d, inclusive, there were 31 deaths from small-pox in
four municipalities adjoining Montreal. Three Rivers, Canada.
— For the week ending September 19th : 5 cases of small-pox;
the disease is increasing. Toronto, Canada. — September 23d:
Free from small-pox. Cardenas, September 12th, Matanzas,
Cuba, September 23d, and Nassau, N. P., September 19th:
Free from epidemic diseases. Guaymas, Mexico. — Consul re-
ports, September 23, yellow fever in Sonora. From September
1st to 23d there were 138 cases and 36 deaths. The disease has
also reappeared in Hermosillo, there having been, from Septem-
ber 7th to 23d, 12 deaths. At Ortiz station several deaths from
•Oct. 3, 1885.)
MINOR PARAGRAPHS.
379
yellow fever have occurred among the soldiers. Vera Cruz,
Mexico. — Consul reports, September 8th, yellow fever still preva-
lent, the mortality being about 50 per cent. La Guayra, Vene-
zuela.— September 5th : Free from epidemic diseases. Carta-
gena, Colombia. — Consul reports, August 28th, that 28 cases of
yellow fever have occurred at intervals during the past three or
four months. Masters of vessels for ports in the United States
generally decline to take bills of health. Callao, Peru. — For
the week ending August 22d : 5 cases of small-pox. Paris,
France. — For the week ending September 12th : 12 deaths from
small-pox. Bordeaux, France. — For the week ending Septem-
ber 12th: 7 deaths from small-pox. Marseilles, France. — Sep-
tember 7th : Cholera reported at Cette. Cadiz, Spain. — Sep-
tember 5th ; Cholera officially declared September 3d. The
average weekly mortality is about 40 per cent. During the
week ending September 3d the mortality was 147. Gibraltar,
Spain. — Five cases and 5 deaths from cholera during the twenty-
four hours ending on September 5th. No new cases were re-
ported. Santander, Spain. — September 10th: Cholera increas-
ing. Genoa, Italy. — September 10th: 2 cases of small-pox.
Rome, Italy. — By telegram September 2d: 4 deaths from chol-
era, nine miles from Genoa, and 5 deaths from the same disease
fifty miles north of Naples. Leghorn, Italy. — By telegram,
September 25th : 3 cases and 1 death from cholera at Pontre-
moli, Province of Carrara. Palermo, Italy. — September 24th:
1,279 cases and 780 deaths from cholera to date. Venice, Italy.
— By telegram September 22d : 5 cases of cholera on the 21st
in towns on the banks of the Po. Trieste, Austria. — Septem-
ber 8th : 26 cases of small-pox ; the disease increasing. Zurich,
Switzerland. — September 5th : 4 deaths from small-pox. St.
Petersburg, Russia. — August 29th: 8 deaths from small-pox.
Warsaw, Russia. — September 5th : 3 deaths from small-pox.
Calcutta, India. — August 15th : 10 deaths from cholera, and 3
from small-pox. Columbo, Ceylon. — August 3d : Cholera re-
ported in Nati veto wn. Shanghai, China. — August 21st: Chol-
era continues among the Chinese in the settlement and in the
city; 1 death among the shipping population. From August
17th to 27th, inclusive, there were in Spain 55,785 cases and
17,856 deaths from cholera. The total number of cases and
deaths from March 4th to August 27th is 214,958 cases and
81,496 deaths.
Japanese Regulations against the Spread of Cholera
from Nagasaki. — Imperial Decree No. 31.— It is hereby de-
creed that vessels arriving from localities infected with cholera
shall be inspected according to the following regulations:
Regulations for the Inspection of VesseU arriving from Locali-
ties infected icith Cholera.
1. All vessels arriving from localities infected with cholera shall be
subject to medical inspection, and no vessel so arriving shall proceed to
her destination or communicate with the shore or other vessels, or land
her crew, passengers, or cargo, until a written permission so to do,
signed by one of the inspecting officers, shall have been so granted as
hereinafter provided.
2. When there are no cholera patients, or bodies of persons who
may have died of the said disease, on hoard such vessels, the inspecting
officers shall forthwith grant permission to such vessels to proceed
to their destination and communicate with the shore or other vessels
and to land their crew, passengers, and cargo.
3. Vessels so arriving and having on board cholera patients, or the
bodies of persons who may have died of the said disease, shall be re-
quired to anchor at a place designated by the inspecting officers at a
safe distance from the land and other vessels.
The patients shall be sent to the Quarantine hospital or to their
residences or other places which the inspecting officers may deem suit-
able. The dead bodies (if any) of persons who may have died of the
said disease shall (at the option of persons interested, if any) be either
burned at a place prepared by the local authorities for that purpose, or
buried, after undergoing thorough disinfection, at such place as the local
authorities may designate.
After final disposition of such patients and dead bodies (if any)
shall have been made, the inspecting officers shall thoroughly disinfect
the crew and passengers, and shall thereupon grant permission for them
to land. The inspecting officer shall thoroughly disinfect said vessels
and such portion of their cargoes as may be considered to be of an in-
fectious character, and thereupon grant permission for them to proceed
to their destination or communicate with the shore or other vessels and
to land cargo.
4. Any person or persons who shall contravene or infringe the pro-
visions of the foregoing regulations, or shall in any manner interfere
with the execution of said provisions, shall be punished according to
the criminal code.
5. The localities where these regulations shall be put in force, and
the length of time for which they shall be continued in force, will be
determined from time to time by the Minister of the Interior.
Dated 23d of the 6th month, 15th year Meiji.
By command of H. I. M. the Emperor.
,a- ji ! Sanjo Sanetomi, Prime Minister.
(Signed) < '
( Yamada Akitosiii, Minister of the Interior.
Personal Items. — Among the passengers who sailed for
Europe by the steamship Etruria, on Saturday last, was Dr.
George M. Sternberg, of the army. Among those who arrived
by the Servia, on Sunday, were Dr. W. S. Ely, of Rochester,
and Dr. T. H. Burchard, of New York. Dr. William S. Halsted,
of New York, sailed for Europe in the Werra on Wednesday.
The Surgeon-Generalship of the Marine-Hospital Ser-
vice.— As we go to press, we learn that the President has de-
cided not to accept Dr. Hamilton's resignation.
The German Faculties. — The "British Medical Journal"
states that Dr. Penzoldt has been appointed to succeed Prof.
Leube at Erlangen, and that Dr. Ludwig Stieda, of Dorpat, is
to succeed Prof. Meckel in the chair of anatomy at Konigsberg.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from September 20 to September 26, 1885 :
Promotions.
McParlin, T. A., Lieutenant-Colonel and Assistant Medical Pur-
veyor. To be Surgeon, with rank of colonel, to date from
September 16, 1885.
Irwin, B. J. D., Major and Surgeon. To be Assistant Medical
Purveyor, with rank of lieutenant-colonel, to date from Sep-
tember 16, 1885.
Pope, B. F., Captain and Assistant Surgeon. To be Surgeon,
with rank of major, to date from September 16, 1885.
Appointment.
Morris, Edward R. To be Assistant Surgeon, with rank of first
lieutenant, to date from September 17, 1885.
Ainsworth, F. C, Captain and Assistant Surgeon. From De-
partment of Texas to New York city, for duty as recorder
of the Army Medical Examining Board. S. O. 214, A. G. O.,
September 18, 1885.
Adair, G. W., Captain and Assistant Surgeon. Granted leave
of absence for one month, with permission to apply for one
month's extensiou. S. O. 104, Department of Dakota, Sep-
tember 18, 1885.
Shannon, William C, Captain and Assistant Surgeon. Granted
leave of absence for four months, to take effect about Octo-
ber 1st. S. O. 215, A. G. O., September 19, 1885.
380
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jocr.
>
Bushnell, George E., First Lieutenant and Assistant Surgeon.
Ordered from Department of Dakota to Department of the
East. S. 0. 219, A. G. O., September 24, 1885.
Naval Intelligence. — Official List of Changes in the Medi-
cal Corps of the United States Navy during the two weeks end-
ing September 26, 1885.
Murray, J. M., Passed Assistant Surgeon. Resignation accepted,
to take effect January 1, 1886.
Ross, J. W., Surgeon. Assigned to special duty at New York.
Dungan, J. S., Medical Director. Waiting orders.
Marine-Hospital Service. — Official List of Changes of
Stations and Duties of Medical Officers of the United States
Marine- Hospital Service, for the five weeks ended September 26,
1885.
Vansant, John, Surgeon. To proceed to New Orleans, La.
September 16, 1885.
Hutton, W. H. II., Surgeon. When relieved, to proceed to Mo-
bile, Ala. September 16, 1885.
Long, W. H., Surgeon. Granted leave of absence for ten days,
September 1, 1885. When relieved, to proceed to Detroit,
Mich. September 19, 1885.
Fessenden, 0. S. D., Surgeon. To proceed to Norfolk, Va.
September 16, 1885.
Sawteixe, H. W., Surgeon. When relieved, to proceed to San
Francisco, Cal. September 18, 1885.
Godfrey, John, Surgeon. When relieved, to proceed to Louis-
ville, Ky. September 16, 1885.
Goldsborough, C. B., Passed Assistant Surgeon. When re-
lieved, to proceed to St. Louis, Mo.
Austin, H. W., Surgeon. To proceed to Burlington, Vt., on
special duty. September 23, 1885.
Society Meetings for the Coming Week :
Monday, October 5th : New York Academy of Sciences (Sec-
tion in Biology); Medico-Chirurgical Society of German
Physicians ; Morrisania Medical Society (private) ; Brooklyn
Anatomical and Surgical Society (private) ; Utica, N. Y.,
Medical Library Association ; Bostou Society for Medical
Observation; St. Albans, Vt., Medical Association; Provi-
dence, R. I., Medical Association ; Hartford, Conn., City
Medical Association ; Medical Society of Monmouth County>
N. J. (Freehold) ; Cbicago Medical Society.
Tuesday, October 6th : New York Obstetrical Society (private) ;
New York Neurological Society; Elmira, N. Y., Academy of
Medicine ; Buffalo Medical and Surgical Association ; Ogdens-
burg, N. Y., Medical Association ; Medical Societies of the
Counties of Broome (annual), Columbia (annual — Hudson),
Orange (semi annual — Goshen), and Schoharie (semi-annual),
N Y. ; Medical Association of Northern New York (annual
— Malone) ; Medical Societies of Hudson (Jersey City) and
Union (quarterly) Counties, N. J. ; Androscoggin County,
Me., Medical Association (Lewiston) ; Chittenden County,
Vt., Medical Society.
Wednesday, October 7th: Medical Society of the County of
Richmond (Stapleton), N. Y. ; Penobscot County, Me., Medi-
cal Society (Bangor) ; Philadelphia County Medical Society.
Thursday, October 8th: Harlem Medical Association of the
City of New York; Society of Medical Jurisprudence and_
Stato Medicine ; Brooklyn Pathological Society ; New York
Laryngological Society ; South Boston, Mass., Medical Club
(private); Pathological Society of Philadelphia.
Friday, October 9th: Yorkville Medical Association (private);
Medical Society of the Town of Saugerties, N. Y. (anniver-
sary).
Saturday, October 10th: Obstetrical Society of Boston (pri-
vate); Worcester, Mass., North District Medical Society.
MEDICAL SOCIETY OF VIRGINIA.
Sixteenth Annual Meeting, held at Alleghany Springs, Tuesday,
Wednesday, and Thursday, September 15, 16, and 17, 1885.
Dr. Bedford Brown in the Chair.
Tuesday's Proceedings.
Medical Societies: their Relations to the Public, was
the title of the annual address to the public and to the profes-
sion, delivered by Dr. II. M. Ci.arkson, of Haymarket, Va.
Medicinal Properties of Alleghany Waters.— Dr. Isaac
WniTE, resident physician at Alleghany Springs, Va., presented
a paper on this subject,' and said that the geological forma-
tions in this section consisted mostly of magnesian limestone
and argillaceous slates. Ores of iron, silver, lead, and zinc were
near by. The water of the Springs had a temperature of 56°
F., and the specific gravity was P00283; it had a saline taste
and a faintly acid reaction. In giving the analysis, he incident-
ally remarked that the effects of baryta and strontia were
somewhat similar to those of arsenic. He had not become such
an enthusiast in regard to the Alleghany water as to claim for
it specific properties for every disease, hut the range of its effi-
cacy was distinct and extensive. He recommended the water
especially in dyspeptic cases, using the term "dyspeptic" in its
generic sense. He believed the magnesian salts in this water
were their great power. Frequently, when first taken, the
water produced a strange feeling in the head — a giddiness which
was often closely followed by decided headache. Erythema, and
even eczema and sometimes boils, developed after using the
water. A glassful, gradually increased to two glassfuls, might
be taken before meals, but the dose must vary according to the
wish for a tonic, diuretic, or cathartic effect.
The Report of the Virginia State Board of Medical Ex-
aminers was read by Dr. W. C. Dabney', of Charlottesville,
President of the Board, who said that thirty-two candidates
had passed satisfactory examinations since January 1, 1885, and
had been licensed to practice in Virginia. Six had been re-
jected. All of the candidates were college graduates.
Wednesday's Proceedings.
The Annual Address was delivered by the president, Dr.
S. K. Jackson, of Norfolk. He considered his elevation to the
highest office in the gift of the society as an evidence of appre-
ciation of his work in prophylaxis as applied to zymotic dis-
eases. The hindrances to the rapid progress of the science ot
medicine, the most important factors in its recent development,
and the most potent agencies to be invoked to secure its con-
tinued growth were also considered.
Scarlet Fever was the subject announced for general dis-
cussion, which was opened by Dr. Thomas J. Moore, of Rich-
mond, who said that he adopted the customary divisions, such
as scarlatina simplex, scarlatina anginosa, and scarlatina malig-
na. He gave graphic descriptions of each form, and traced the
history of the disease from its earliest mention down to the
present day. He discussed the origin of the fever, and laid
much stress upon the germ theory. The success in cultivating
and inoculating the special microbes of charbon, chicken chol-
era, murrain, and other diseases in the lower animals, with
modification of symptoms and abatement in the severity of the
Oct. 3, 1885.]
PROCEEDINGS OF SOCIETIES.
381
respective diseases, was described, and the hope expressed that
corresponding advances in human parasitology might follow
close in its wake. He stated that up to the present time the
only germ that had filled all the necessary requirements, as
found in man, through inoculation and otherwise, was the spiro
bacterium of relapsing fever found by Oberrneier and called
after him. The parallelism between small-pox and charbon was
alluded to, traveling, however, in opposite directions — the one
from man to the lower animals, the other from the domestic
animals to man ; the special bacillus of the latter had been dis-
covered ; through cultivation and inoculation it fulfilled all the
law required of it; like vaccination in small-pox, it produced,
through inoculation of a remote culture from the virus of one
of the lower animals, immunity in the human family ; the pecu-
liar microbe producing the former had not yet been determined ;
he hoped that it would come to light at no distant day. Fur.
ther, he stated that there were two microbes described as giving
origin to scarlatina — the monas scarlatinosum of Klebs, the plox
scindem of Eklund, of Stockholm. Each was ingeniously and
plausibly put forward as the true bacillus. Klebs did not in-
dulge in the enthusiasm peculiar to his confidence, while Eklund
endeavored to demonstrate the absolutism of his proposition.
Dr. Moore did not think that belladonna possessed prophy-
lactic powers, and declared it to be an indifferent drug when
used to mitigate symptoms during the process of the disease.
For the reduction of temperature he preferred the ice-cap to
the head, rubber bag over the front of the neck and covering
the great vessels, conjoined with sponging; failing in this, he
used wet sheet, then cold pack, and, as a last resort, the cold
bath as described by Ziemssen. He never feared the depressing
effects of cold water, as patients could always be relieved from
impending congestion by free resort to alcoholic stimulation.
His favorite internal antipyretic up to this time was quinine —
administered by rectum or hypodermically where the stomach
was irritable; he hoped much from resorcin, and urged his
brethren to try it and give to the world their clinical experi-
ence. The drug was safe, certain in action, a germ-destroyer.
As an unguent, especially where itching and burning were promi-
nent symptoms, he knew nothing equal to a combination of
glycerin, borax, and carbolic acid. He recommended sprays as
the most efficacious manner of applying internal medication to
the throat, and called especial attention to the value of hydrate
of chloral, two to four grains to the ounce, as invaluable for
antiseptic and anodyne powers. The doctor recommended the
use of small doses of mercury for a few days as an adjuvant to
diuresis, in the dropsy attending acute desquamative nephritis,
where diuretics were not accomplishing the desired end. Fail-
ing with these, a resort to hydragogue cathartics was indispen-
sable. Nutritious food from the commencement of an attack,
and free stimulation in all cases where the vital powers were
depressed, he regarded as indispensable.
Election of Officers. — At the afternoon session the follow,
ing-named gentlemen were elected officers for the ensuing year:
Dr. John S. Apperson, of Town House, President ; Dr. T. B.
Grker, of Rocky Mount, and Dr. H. M. D. Martin, of Fred-
ericksburg, Vice-Presidents ; Dr. Landon B. Edwards, of Rich-
mond, Recording Secretary ; Dr. R. T. Styll, of Richmond,
Treasurer; Dr. Hugh T. Nelson, of Charlottesville, to deliver
the " Address to the Public and to the Profession " in 1886; Dr-
Thomas J. Moore, of Richmond, Examiner-at-large on the State
Board of Medical Examiners; Dr. Hugh M. Taylor, of Rich-
mond, Examiner from the Third District ; Dr. Meade 0. Kemp-
er, of Norfolk, Examiner from the Second District; Dr. L-
Ashton, of Falmouth, to open the discussion on " Puerpera
Septicaemia" in 1886. The next session will be held in Fred-
ericksburg, in November, 1886.
The Discussion on Scarlet Fever was continued by Dr.
Bedford Brown, of Alexandria, who said that he had seen
malignant cases with cold extremities and tongue with a body
temperature of 107° F. He used :
R Acid, salicylat 3 ij ;
Tinct. aconit. radicis gtt. xij ;
Infus. digitalis § jss. ;
Spts. amnion, aromat 3 iij ;
Syr. aurant. cort § ss. ;
Aquae ,. § j.
M. S. Teaspoonful for a child five years old every three
hours.
This combination reduced fever more decidedly than any
other antipyretics he had used ; it acted also as a diaphoretic
and diuretic. A tepid bath or a wet pack increased its action.
Alcoholic stimulants benefited malignant cases, tending to col-
lapse and coma, as also cases, on the other hand, having high
fever, rapid pulse, and extreme restlessness. Such agents also
generally arrested adenitis. In dangerous cases, frequent baths
were too exhaustive. When extensive suppuration and pyaemia
threatened, tincture of iron, Fowler's solution, and quinia sul-
phate acted well. To arrest acute nephritis and renal dropsy,
he enveloped the body with a fiaxseed-meal poultice covered
with oil-silk. When the kidneys were engorged, the urine
bloody, with dropsy of the chest and abdomen, a full dose of
calomel, followed by compound powder of jalap, would often
do good. Such cases bore purgation. But if the renal dropsy
was attended with cool skin, great pallor, feeble pulse and great
prostration, then frequent purgation was not well borne. In
such cases he used lumbar poultices, digitalis, acetate of potash,
with occasional saline cathartics. A morbid element in scarla-
tina often developed rheumatism ; hence frequent cardiac com-
plications. When these occurred he resorted to the active
agents named in the foregoing prescription. Alkalies and salines
should be used in renal complications. Dr. Brown had been
disappointed with the diaphoretic action of pilocarpin. Potas-
sium iodide was often useful in nephritic sequelae of scarlet
fever.
Dr. R. I. Hioks, of Casanova, Va., had never seen anything
indicating relationship between scarlet fever and diphtheria,
nor had he seen scarlatinal throat complications threaten life.
Mopping the throat or gargling hot water would relieve the
faucial troubles. He thought the best treatment of scarlet
fever consisted in cold sponging the body, and the use of qui-
nine and small doses of carbolate of iodine internally.
Dr. Alexander Harris, of Jeffersonton, Va., emphasized
(1) the benefit of isolation, both to prevent and to cure scarlet
fever; (2) sick rooms with open fire-places; (3) the bed should
he out from a corner of the room, and draughts of fresh air
should keep- the room ventilated; (4) the patient's and the bed
clothing should be daily changed ; (5) the popular disinfectants
were not useful in permissible doses. Fire or water above 212°
was the best germicide. Hence burn or boil all clothing that
had been about the patient. (6) Always disinfect a house in
which a zymotic disease had been treated, if even a year or two
previous. Pour boiling water over the floors, in the cracks, on
the walls, etc. Steam would be better.
Dr. C. F. Lewis, of Clifton Forge, Va., believed in the stimu-
lating plan of treatment, and thought digitalis helped to relieve
the swelling of the throat. Sometimes he used chlorate of
potash and muriated tincture of iron. He was a strong advo-
cate of such sanitary measures as Dr. Hicks and Dr. Harris had
just mentioned. He fed liberally.
Dr. John F. Winn, of Richmond, agreed with the speakers
as to their sanitary recommendations. He thought, in towns
382
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Joub.,
especially, placards should be placed on doors of infected houses
as warnings to comers-in. Public funerals in all cases of death
by zymotic disease should be prohibited by law. In the sick-
room, old cloths, etc., should be used, which might be destroyed
by fire. The popular "disinfectant solution" of copperas was
not a disinfectant, but was antiseptic. Four ounces of chloride
of lime dissolved in a gallon of water was a good preparation to
pour over the evacuations of typhoid patients. Corrosive subli-
mate in solution was also used. Let all articles that were to be
used again be kept immersed in one or the other of these solu-
tions for several hours. To disinfect a room, burn in it from
two to four pounds of common sulphur, with closed doors. If
the body after death was to be moved, it should be kept
wrapped in cloths wet with Labarraque's solution — § iv to the
gallon.
Dr. L. Lankford, of Bowers, Va., agreed with the speakers
as to the importance of fresh air in the treatment of scarlet
fever, and thought that malignancy would be rare if this were
more insisted upon than it was. As an illustration, he men-
tioned the cases of two of his children. The younger was kept
down-stairs in a warm room, with the doors closed, and malig-
nancy developed ; the other child was kept up-stairs, where
there was no fire -and where a window was kept open, and no
malignant sign or symptom developed. The weather was cold.
Br. J. Herbert Claiborne, of Petersburg, Va., spoke of a
case in his practice in which the dermic inflammation was so
intense that on the third day the skin came off in large patches
all over the body. Some children played day after day in the
room with the patient, and yet none of them contracted the
disease. Shortly afterward some other children had the fever
so mildly that they could not be retained in the house; but in
a short while the disease developed in some of their playmates.
An old lady living in the house with these mild cases had scar-
let fever so severely that she came near dying. To disinfect a
sick-room, not only the organic germs must be destroyed, but
the spores also. A solution of corrosive sublimate (1 to 1,000)
was required to kill the spores, or water at 280°. But the best
disinfectant for a sick-room after all was pure fresh air. The
doors and windows should be left open. Of course always dis-
infect articles of clothing, etc. He thought Squibb's solution
of chlorinated soda — § ij to the gallon of water — was the most
perfect insecticide in the market, and it was cheap enough to
be within the reach of all.
Dr. William L. Robinson, of Danville, Va., believed that a
great deal of good resulted from proper medicinal treatment.
He reduced the fever by using a full bath at 95°, which he al-
lowed to cool down to 85° while the patient was in it. Before
taking him out of the bath he gave a weak toddy, and rubbed
the body over with camphorated oil before he was put to bed.
He depended very much upon the free use of lithia water as a
drink. If the nose got stopped up so as to compel mouth-
breathing, the child waked up often from cat-naps with screams.
For this condition he used the steam atomizer — two grains of
chloral hydrate in an ounce of water. This kept the nose
moist. Large doses of calomel and jalap should be used if kid-
ney complications supervene. In one case of oedema of the
lungs the hypodermic use of pilocarpin saved the patient.
Dr. Winn stated that a recent correspondent iu the "Jour-
nal of the American Medical Association " placed his diphthe-
ritic patients on house-tops or on the porches, and said that all
got well. The more fresh air, the better were the results of
treatment.
Dr. W. W. Parker, of Richmond, Va., had often been dis-
heartened at the results of treatment of scarlet fever. Many
cases, it is true, got well without any special treatment; but,
until of late years, other cases did not get well under any plan.
Now, however, he had better results, and he thought the best
remedy for malignant cases was alcohol in free doses. He kept
his patients hot. He obtained the suggestion from the good
effects of alcohol in typhoid fever. Applications of turpentine
were as good for the sore throat as carbolic acid. Keep the
child in the house, according to the weather. In the summer
the patient might go out in ten days; but in winter wait three
or four weeks.
Dr. M. A. Wilson, of New River Depot, Va., had used
Bartholow's tincture-of-belladonna prescription, to antagonize
that condition of the throat which caused exudation, with great
satisfaction.
Dr. Hugh T. Nelson, of Charlottesville, Va., thought pa-
tients often succumbed to accumulations of heat around the
nerve- centers ; hence the necessity for diaphoretics and heart
stimulants. Afterward tonics should be used.
Dr. S. K. Jackson, Dr. R. S. Lewis, of Culpepper, Dr. W. L.
Broaddus, of Newtown, Dr. JohnGrammer, of Halifax Court-
House, and Dr. W. D. Cooper, of Morrisville — all spoke in the
highest terms of Watson's chlorine treatment as described in
his work on " Practice of Physic."
The Report on Chemistry, Materia Medica, and Thera-
peutics was made by Dr. M. ft. Ellzey, of Washington, D. C,
who first considered the position of chemistry in medical schools.
The report advocated the demand for proficiency in elementary
chemistry in medical students before matriculating, and then
teaching them practical chemistry, as urinalysis, toxicology, etc. .
In materia medica and therapeutics cocaine and antipyrin were
alluded to. No germicide could be safely applied to an absorb-
ing surface. In climatology, Dr. Ellzey thought the Appala-
chian portion of Virginia the best of sanitariums for summer
and fall. For the year round the climate of southern North
Carolina and northern South Carolina was the best. The aver-
age amount of carbonic acid in a European atmosphere was
about 4 to 10,000, whereas at Washington, D. C, it was 3 to
10,000 parts. The pyrogallic-acid tests of the percentage of
oxygen in the air at Washington showed a close coincidence
with European air — about 20-70 per cent, for out- door air.
He thought a rich harvest awaited climatological-therapeutical
studies in the near future.
The Report on Advances in Obstetrics and Diseases of
Women and Children was presented by the chairman of the
committee, Dr. Smelt W. Dickinson, of Marion, Va. He called
attention to the changes in practice during the year regarding
antiseptic midwifery. Intra-uterine post-partum injections with
even weak solutions of corrosive mercury were, he thought,
dangerous. The parts should be kept clean. The important
thing was to render aseptic everything that entered the vagina
— the hands, sponges, instruments, etc. The readiest way to
effect post-partum drainage was to place the patient upon the
chamber-pot, if her strength allowed, when she wanted to urin-
ate, etc. He thought the contagium of puerperal fever was of
a material nature, capable of being washed away or destroyed by
antiseptic injections. If the discharges became offensive and
the body temperature rose above 100° F. without plain cause,
resort should be immediately had to antiseptic washes. In
answer to the question, How long before a doctor in attendance
upon a puerperal-fever patient might safely attend another de-
livery? Dr. Dickinson said the weight of opinion was that he
might safely do so at once provided he thoroughly antisepticized
himself and clothing. Extra-uterine pregnancy might be treated
by killing the foetus by electricity and then performing laparot-
omy. Combined version in placenta prajvia was now the ap-
proved plan, and was thus executed : The vagina was tamponed
so as to obtain sufficient dilatability. The patient was then
anaesthetized ; the hand was passed into the vagina and two
Oct. 8, 1885.]
PROCEEDINGS
OF SOCIETIES.
383
fingers inserted through the presenting placenta and the foetus
drawn to one side, while the other hand, on the abdomen, pressed
the child so as to carry its buttocks down until a foot could be
reached. The foot was drawn through the cervix so that the
breech might act as a tampon on the lower segment of the
uterus. Then spontaneous delivery was awaited, or for suffi-
cient dilatability of the cervix to permit delivery. Crede and
Weber preferred absorbent cotton as a daily dressing for the
cord, which, they claimed, prevented umbilical inflammation.
Ethyl-bromide promised well as an obstetric anaesthetic. Co-
caine was subjudice. Obstetric forceps were invaluable. Abor-
tion should be produced when danger threatened. The tempera-
ture of the lying-in room should be well regulated. Swinging
the body was advocated as a substitute for artificial respiration.
Of diseases of women, neurasthenia was the most common,
and all that 'Dr. Weir Mitchell had said about it— both as to
cause and treatment — was indorsed. Operative interference
with lacerations of the cervix uteri was now opposed, as the
lacerations healed well if left to themselves. Alexander's oper-
ation for backward uterine displacements was described. Dr.
Goodell preferred rapid dilatation of the cervix uteri for dys-
menorrhoea of an organic nature, and also for nervous dysmenor-
rhcea.
In diseases of children, he remarked upon the advantage of
large doses of carbonate of ammonia^for scarlatina. Dr. Huf-
fard, of Smyth County, Va., depended on the carbonate later
in the disease, when languid capillary circulation set in. Bis-
muth subnitrate was recommended to be powdered over the
sore tongue which usually occurred about the fifth day — just as
in cancrum oris. Trypsin in spray form every fifteen minutes
or more, if the patient's strength would permit the operations,
was a solvent of diphtheritic membrane. Chlorate of potash
should be avoided in febrile diseases where the blood was alka-
line, as in diphtheria, nephritic affections with scanty urine, in
uraemia, etc. Incomplete closure of the ductus venosus was
thought to be the cause of icterus neonatorum. Dr. Marion
Sims's view that trismus nascentium was due to " an inward
displacement of the occipital bone " was supported by Dr. Har-
tigan, of Washington, D. C.
{To be concluded!)
AMERICAN GYNAECOLOGICAL SOCIETY.
Tenth Annual Meeting, held at Washington, Tuesday, Wednes-
day, and Thursday, September 22, 23, and 24, 1885.
(Concluded from page 357.)
The President, Dr. William T. Howard, of Baltimore, in the
Chair.
Wednesday's Proceedings.
The President's Annual Address.— The President read
bis annual address. It was entitled "Two Rare Cases in Ab-
dominal Surgery."
Case I. — S. H., a negress, aged twenty-four years, married,
presented herself at the dispensary of the University of Mary-
land April 20, 1882. She was seen by the clinical assistant and
the following notes were made : Menstruation appeared at the
age of fourteen, and had been regular and normal. She was
the mother of five children, the youngest of which was two
months old. She had never had a miscarriage. Some days
after delivery she noticed an enlargement in the lower portion
of the abdomen, which gradually extended in the middle line
until it reached the umbilicus, and was attended with bearing-
down pains and frequent micturition. On examination, fluctua-
tion was found well marked all over the abdomen, with de-
cided resonance about the umbilicus. There was dullness on
percussion and there was bulging in both flanks. Six weeks
later she returned to the dispensary, and at this time the reso-
nance at the umbilicus had disappeared and the umbilicus pro-
jected. The author saw her for the first time two weeks after
this observation was made. She was then quite sick, the tem-
peratnre being 102° F., the pulse 132, and the respiration 32.
Examination showed the presence of fluid in the pleural sac.
There were also some crackling rales. The abdomen was as
large as at the seventh month of pregnancy and was remarka-
bly protuberant in the center. There was complete dullness
over the entire abdomen, not changed by change of position.
There was no evidence of a solid tumor, but it had every ap-
pearance of a simple unilocular cyst. Vaginal examination
showed the uterus well in front of the tumor, and the sound
gave a measurement of two inches and three quarters. The
question which arose was as to the nature of this tumor. Was
it ovarian? The extreme infrequency of ovarian tumors in the
negro race was against this view. The rapid growth of the
tumor was also opposed to it. The next affection considered
was fibro-cystic tumor of the uterus. This was exceedingly
rare. The speaker bad seen but one such case in the negro
In that case the cyst was filled with pus. The patient was op-
erated upon with a fatal result. Such tumors were rare before
the age of thirty-five. They usually developed slowly. There
was no menstrual disturbance in this case. For these reasons,
fibro-cystic tumor was excluded. Was it a parovarian cyst?
These usually developed even more slowly than ovarian cysts.
They were usually flaccid, contained a thin liquid, were com-
paratively rare, and did not affect the general health. This was
therefore excluded. It was certainly not a case of simple as-
cites, but was it a case of encysted dropsy of the peritonaeum,
so called, resulting from simple peritonitis? This was an ex-
tremely rare affection, and in the early stages there were symp-
toms of constitutional disturbance; the abdomen was not promi-
nent and often it was flaccid. Encysted dropsy was excluded.
Finally, on June 20th, he aspirated the cyst under antiseptic
precautions. The fluid which escaped was of a light straw-
color and coagulated as speedily as blood. After aspiration,
large masses were readily felt through the abdominal wall.
The character of the fluid corresponded with that which was
said to characterize fibro-cystic tumors of the uterus. The
speaker bad, however, seen other cases which showed that the
character of the fluid was not pathognomonic. In one case of
abdominal tumor, fluid was removed which did not coagulate
even after being kept for many days. The abdomen was sub-
sequently opened and a fibro-cystic tumor found. In a case of
supposed ascites in a man, aspiration was performed and the
fluid removed coagulated quite rapidly.
After the cyst was aspirated the patient did well for three
days, when acute peritonitis supervened and she died on the
seventh day. At the autopsy a mass as large as a child's head
was found in the abdomen. This consisted of omentum, the
transverse colon, and small intestine bound together by inflam-
matory exudation. The inflamed peritonaeum was invaded
everywhere with miliary tubercles. There was no ovarian or
uterine disease. There was some tubercular ulceration of the
small intestine; the other abdominal organs were not affected.
The pleura was also invaded with scattered miliary tubercles.
In both lungs there were some tubercles.
This, then, was a case of encysted tubercular peritonitis
simulating ovarian or parovarian cyst. The failure to recog-
nize the true condition was ascribed to want of attention to the
previous history of the case and the non-recognition of the
fact that there had been free fluid in the peritoneal cavity at
the first visit.
The speaker then referred to the few similar cases which
384
PRaCKhJJlSUS
OF SOCIETIES.
|N. Y. Mkd. Jock.
had been reported. In these cases the disease had appeared as
a rule under the age of twenty-five years. It had progressed
rapidly, the length of time varying from six weeks to eight
months.
Case II. — F. R., aged twenty-four, was admitted to the
hospital in July, 1883. She professed to belong to the colored
race, but looked much like a white woman. She had been mar-
ried a year, but had never been pregnant. There was no evi-
dence of uterine disease. The abdomen was much enlarged,
measuring forty-seven inches just below the umbilicus. Vagi-
nal examination showed the uterus pushed forward by a sac
containing fluid. There was apparently an immense unilocular
sac. This had been first noticed seven or eight years before.
The increase in size had been gradual and unaccompanied with
pain. As to diagnosis, ascites was dismissed both on account
of the physical signs and the absence of any cause to account
for such a condition. The length of time which the affection
had lasted was against its ovarian origin. There were, how-
ever, exceptional cases in which an ovarian tumor might be
present for a number of years, even as many as twenty-four,
without requiring operation. The age of the patient, the
length of time which the cyst had been present, the marked
fluctuation, and the flaccid nature of the tumor, were in favor
of a parovarian cyst. There was one point against this diag-
nosis, and that was that, although the cyst was flaccid, it could
not be compressed below the umbilicus. Fibro-cystic tumor
was readily excluded. The history of the case was against the
existence of encysted peritonitis. The balance of evidence
seemed to be in favor of an ovarian or parovarian cyst.
On July 13th the operation was performed. It was done
largely with the view of exploration. The peritonaeum was
found much thickened and closely adherent to the sac. With
difficulty the adhesions were separated for a short distance, and
the cyst presented tiie appearance of an ovarian cyst. A trocar
was introduced and forty pounds of a greenish, viscid fluid were
removed. An endeavor was made to enucleate the cyst, but the
adhesions were so extensive that this could not be accomplished.
The cyst was then incised to the extent of the abdominal open-
ing, and, on looking into it, it appeared to occupy the whole
abdominal cavity, stretching tightly over the spinal column. A
small portion of the wall of the cyst was removed, a drainage-
tube introduced, and the opening closed with stitches. Perito-
nitis ensued and the patient died. A post-mortem was made,
but, owing to the' speaker's unavoidable absence, was not suffi-
ciently full to throw any more light upon the case than had
been obtained at the operation. The nature of the cyst there-
fore remained unsettled.
Dr. T. A. Emmet, of New York, said that the older he got,
and the more experience he had, the more uncertain he was
about diagnosis. When a woman had an abdominal tumor he
favored opening the abdomen to make the diagnosis, because
she had something which must come out. As to rapidity of
development, it could not be depended upon. He had seen
parovarian cysts develop in six weeks; he had also seen cases
which had lasted twenty-three years. About two years ago he
saw a case in which he could not make a diagnosis. The abdo-
men was opened and just such a cavity as had been described
was found. It seemed as though a cyst had at some time rup-
tured and its contents had become encysted. The cavity was
left open and frequently washed out. In six weeks its size had
greatly diminished. Unfortunately, the patient died at this time
from strangulation of the small intestine.
Dr. William Goouell, of Philadelphia, said that he had
removed tumors the nature of which he did not know to this
day. In one case he worked for forty-five minutes before find-
ing out what the tumor was. It turned out to be two ovarian
tumors which had coalesced, including the uterus between them.
He felt more and more the necessity of performing the explora-
tory operation, for without this it was impossible to make a
correct diagnosis in many cases. To illustrate the difficulties of
diagnosis, he reported a case seen some time ago. A lady pre-
sented herself with a solid tumor of the abdomen. There were
also metrorrhagia and raenorrhagia. He diagnosticated fibroid
tumor of the uterus, but the growth was so mobile as to sug-
gest the possibility of a fibroid tumor of the ovary, and it was
so noted at the time. An operation was not recommended.
The lady went North, and her sufferings became so great that
she consulted a distinguished gynaecologist, desiring an opera-
tion. The operation was performed, and a large fibroid of the
ovary removed.
Dr. T. A. Reamy, of Cincinnati, wished to put on record
another case in which a fatal result followed aspiration in tu-
bercular peritonitis. The patient was a man, but the enlarge-
ment presented all the characteristics of an ovarian cyst. Death
took place the second day after the removal of the fluid.
The President thought that in the majority of cases a cor-
rect diagnosis could be made. The fact that he was able in
these cases to eliminate so many of the ordinary conditions
which gave rise to tumors showed that we had the means of
making the diagnosis generally. The object of the paper was
to give an accurate account of these cases in order that it might
assist others in cases of obscure abdominal tumors.
The Care of the Perinseum during Labor. — Dr. Reamy
read a paper with this title. He referred to the various opin-
ions which had been expressed on this subject. There was a
general agreement as to the importance of preserving the peri-
nteum. In certain cases, however, from anatomical and patho-
logical conditions, laceration was almost inevitable. The author
then spoke of the various methods which had been proposed,
dividing them into two general classes — those which aimed to
support the perinseum, and those which were used with the
object of retarding the progress of the head. There was one
class of authors, numerically small, who believed that the peri-
namm should be let alone.
The method about to be described he had adopted several
years ago, anil it had given him much satisfaction. He was
persuaded that he had satfed many perinea by its use. It was
recommended for primipara? and others where the structures
were greatly imperiled. During the early part of the second
stage the patient was allowed to assume any position she pre-
ferred, but, when the head began to distend the perinseum, she
was placed across the bed with the limbs in the lithotomy posi-
tion with the exception that the knees were kept close together.
This was important. The limbs were held in that position by
two assistants. A piece of muslin or a towel, ten inches wide
and forty or fifty inches long, was carried around the buttocks
of the patient and over the hemisphere produced by the bulging
perinseuin, with the upper edge on a level with the fourchette,
and the ends were given to the assistants, who were instructed
to make traction during the pains in the manner that the ac-
coucheur might direct. The bandage must he applied smoothly.
The force might be exerted in any required direction. Care
must be taken, however, that the pressure was equally dis-
tributed and that the assistants did not simply pull on the mid-
dle or posterior part of the bandage while the anterior portion
was left lax. In order to show that this procedure was based
on good anatomical grounds, the speaker next referred to the
anatomy of the perinaeum, illustrating his remarks with dia-
grams. According to the old descriptions of the anatomy of
this region, it was considered that the muscular fibers decus-
sated in the part between the vagina and the rectum. Recent
observations showed that this was not the case, but that the
Oct. 3, 1885.1
PROCEEDINGS OF SOCIETIES.
385
fibers simply met, and a laceration of the perinseum divided no
muscular fibers transversely, with the exception of those of the
transversa peri nasi. The fibers were simply separated. When
the sphincter ani was divided, its fibers were of course divided
transversely. The perinseum was prevented from laceration by
the protection afforded by the tissue below and the integument.
The bandage used in the way described afforded a supplement-
ary perinseum as it were. By keeping the limbs in the position
indicated we enabled nature to supply tissue for the relaxation
of the perinseum. When the perinasum bulged the sulci at the
sides disappeared, and the perinseum with the advancing head
formed almost a hemisphere. The towel was in contact with
every part of this hemisphere. The advance of the head might
be retarded by making traction on the towel. Where it was
accessible a narrow bed might be used with advantage, the assist-
ants taking their positions near the head of the patient. The
use of this bandage avoided any tendency to exciting expulsive
efforts from reflex irritation of the perinseum as was sometimes
seen where the fingers were used. It was comfortable to the
patient and did not cause more exposure than other methods.
The bandage might be kept on until the shoulders were born,
thus avoiding rupture from this cause. In order that this
method should be successful, it was important that every detail
should be carried out with painstaking care. Should a rupture
occur, the immediate operation should be resorted to.
Dr. M. D. Mann, of Buffalo, said that the method seemed a
good one in a certain proportion of cases, but he had seen some
cases where it would have been of no avail. The worst rup-
tures occurred in cases where, at the acme of the final expulsive
pain, the woman had torn herself from the accoucheur. In
such cases the use of chloroform would of course obviate the
difficulty. Another objection to the method was that it re-
quired more assistance than could always be secured.
Dr. J. R. Chadwiok, of Boston, thought the term "support-
ing the perinaaum " a misnomer. What was meant was retarda-
tion of the child's head until the tissues could be sufficiently
stretched to permit its passage. He always insured the slow
exit of the head and did not permit it to escape during a pain.
The method which he employed was to have the patient on her
side, and then pass one arm over the thigh. Then, by inter-
locking the fingers, any desired amount of pressure could be
made.
Dr. Ellwood Wilson, of Philadelphia, had tried every meth-
od suggested for the support of the perinseum, with the ex-
ception of the one just described by Dr. Beamy. His usual
plan was simply to instruct the woman to keep her mouth open
during a pain and pant.
Dr. Reamy, in reply to the statement of Dr. Chad wick, that
supporting the perinseum was a misnomer, said that the word
support meant protection or succor, and had been used in this
sense. The number of assistants required had been objected to,
but the importance of preventing rupture of the perinseum in
the first labor was so great that, even if two or three skilled as-
sistants were required, they should be employed. With this
method the patient could not get away. An objection to the
method referred to by Dr. Chadwick was that the pressure was
not made over the perinseum, but over the head, and extension
migbt be produced, causing the head to come into a bad relation
to the axis of the outlet. In cases in which the head had been
permitted to remain pressing on the perinseum for some time,
the tissues were in a state of beginning necrosis and exceedingly
friable. Even in such a case the use of the towel or bandage
lessened the perils of the perinseum, and it would often be saved
where otherwise it would have been torn. It could not be sup-
ported with the hand under such circumstances. If it was de-
sired, the forceps might be applied with the bandage in position.
A Case of Caesarean Section. — Dr. Edward W. Jenks, of
Detroit, described the following case, which he had seen in con-
sultation. The patient, aged twenty-seven, had given birth to
one child five years previously without special difficulty. Two
years later she received a fracture of the ilium from a building
falling on her. She was taken in labor at three o'clock in the
morning. The physician in attendance, finding some difficulty,
tried to apply the forceps. He got one blade on without diffi-
culty, but could not, after several trials, introduce the second
blade. He sent for assistance, and the attempt to apply the
forceps was again made without success. The cause of difficulty
was a projecting shelf of bone at the seat of fracture. Another
physician was called in aud the forceps was again tried. It was
then decided to perform craniotomy, which was done, but still
the head could not be made to descend. Dr. Jenks was then
sent for. He tried to apply the forceps to make sure that it
could not be applied, and, failing, tried the cephalotribe with no
better success. It was then decided to perform abdominal sec-
tion. This was performed at two o'clock that night, twenty-
four hours after labor began. The woman appeared to be in
good condition. The placenta was found attached directly under
the incision and there was alarming hsemorrhage, which, how-
ever, was quickly checked by the rapid extraction of the foetus.
The edges of the uterine incision were brought together by silk
sutures and the abdominal wound was closed. The patient did
well until three days after the operation, when she suddenly
died. It was subsequently learned that the nurse had, in dis-
obedience to orders, temporarily left the room, and that in her
absence the patient got out of bed. She complained of feeling
something give way, experienced severe pain, and died in a few
hours.
Dr. A. J. C. Skene, of Brooklyn, remarked that in such
cases the chances of the patient were lessened by undue efforts
at delivery with the forceps. He thought that this would have
been a good case for the performance of laparo-elytrotomy. It
was impossible to sacrifice the child by that operation if it was
performed in good time. He could hardly imagine any case
where craniotomy should be performed, except possibly where
the head wassoengaged in a small inferior strait that it could
be extracted in no other way. Even then he was not certain
that the Csesarean section would not be the best operation.
Dr. Jenks said the operation of laparo-elytrotomy was dis-
cussed, but it did not seem to be an easy operation under the
circumstances. If it had not been for the unfortunate accident
in this case, the woman would probably have recovered.
The Use of Tarnier's Forceps.— Dr. Ellwood Wilson read
a paper on this subject at the meeting in 1881. He had offered
a number of objections to the use of this forceps. His objec-
tions had been based on theoretical grounds. The object of the
present communication was to report nine cases in which he
had used the forceps with decided advantage to the patient. He
had therefore modified his views as before expressed. A de-
tailed account of the nine cases in which the forceps had been
used was then given. The instrument used had been Dr.
Howard's modification of Tarnier's forceps.
Dr. Mann had used the Tarnier forceps for the past two
years in a number of cases with, in the main, satisfactory re-
sults. In one case of deformed pelvis in which the Tarnier for-
ceps was applied, the child was injured by it. The outer edge
of one orbit had been crushed in, destroying the eye. The child
was living at the time of birth, but subsequently died.
The President said that, so far as he knew, ho was the first
to use the Tarnier forceps successfully in America. In cases of
occipito-posterior positions, the application of other forceps in-
terfered with the. rotation of the head, but with the Tarnier
forceps the head was free to rotate.
386
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
Thursday's Proceedings.
A Modification of Emmet's Cervix Operation in certain
Cases, with a Case.— Dr. R. Stansbury Sutton, of Pittsburgh,
read a paper in which he stated that, while the operation was
original so far as he was concerned, he did not profess to be the
only one who had performed it. Cicatricial tissue was found to
a greater or less extent in every case of lacerated cervix which
had lasted for any length of time. This was especially apt to
be the case where nitrate of silver had been used in the treat-
ment. The hardened tissue might be present in both lips, or it
might be limited to one lip. The patient whose case was re-
ported was operated on June 5, 1885. She was the mother of
several children. There was a double maceration of the cervix.
The tissue of the anterior lip was hardened and hypertrophied,
and the lip was convex from side to side and also from before
backward, so that by the ordinary method of operation correct
coaptation could not be effected. The tissue of the anterior
lip was as hard as cartilage. Ordinary denudation of the pos-
terior lip was sufficient, and this was made, leaving the strip of
mucous membrane somewhat wider than usual. The cicatricial
mass involving the anterior lip was removed from border to
border, completely denuding this portion of the cervix. The
parts were then brought together in the usual way, and the re-
sult was excellent. The cervical canal readily admitted a sound,
and the woman menstruated without difficulty. The speaker
thought that there were cases in which nothing short of the
complete removal of the cicatricial tissue would be sufficient.
Dr. Goodell had resorted to this device on more than one
occasion, and also to another plan on a few occasions. That
was to outline the strip of mucous membrane to be left, and to
dissect it from the tissues below, leaving it united at its base.
The indurated tissue had then been removed and the flaps
brought together. The result had been good.
Dr. Skene remarked that this was not cicatricial tissue ; it
was a true sclerosis — a hyperplastic, indurated tissue. This
was, however, simply a question as to name. Much could be
done to get rid of this tissue by preparatory treatment. But
this often required too much time, and then such an operation
as that proposed by Dr. Sutton came in. His plan had been to
do a preliminary operation, consisting in removing a transverse
wedge-shaped piece from one or both lips of the cervix, as the
case might require, and then bringing the surfaces together
with silk stitches. After the first day the patient could go
about, and the sutures were removed in the course of a wreek
or ten days. After the size of the cervix was reduced the or-
dinary operation was performed. He had done both operations
at one sitting, but preferred to do them separately. One objec-
tion to the method of Dr. Sutton was that it left cicatricial
tissue.
Dr. George J. Engelmann, of St. Louis, said that in old and
severe cases it was impossible to retain the strip of mucous
membrane. He therefore removed it. He had done this on
both lips, and on some occasions had complete union, but the
passage of a probe served to keep a canal open. For the last
few years he had paid no attention whatsoever to this central
strip. To prevent union he inserted a single piece of the car-
bolized-silk thread which was used in closing the opening. A
probe passed a few times after the removal of the sutures
would dilate the canal. The result of this operation had been
good. The union, the involution, and the restoration of the
health of the patient had been perfect. This operation had
been done only in severe cases, and, so far as he knew, none of
these patients had conceived.
Dr. Mann had tried the method described by Dr. Sutton.
In only one case had it been necessary to denude both surfaces.
To insure a patulous canal, he introduced a piece of small drain-
age-tube. The patient did well.
Dr. W. H. Baker, of Boston, thought the retention of the
mucous membrane of importance. The method of Dr. Sutton,
by leaving cicatricial tissue on one side of the canal, would tend
to make the canal tortuous. As a rule, if the patient was prop-
erly prepared, it would not be necessary to remove this hyper-
trophied tissue. If this was not done, Emmet's operation could
still be performed in the way described by Dr. Skene. He pre-
ferred to do both operations at the same time. It was then not
necessary to introduce a suture to bring the transverse incision
together. Great care should be exercised in the introduction of
substances between the two flaps.
The President remarked that a few weeks before the death
of Dr. Sims he had seen Dr. Harry Sims perform this operation
in the presence of his father. He inserted a glass tube which
fitted so loosely that it had to be retained with a plug of
cotton.
Dr. Skene thought that if the denudation was practiced on
both sides stenosis would certainly follow.
Inflammation of the Parotid Glands following Opera-
tions on the Female Genital Organs.— Dr. Goodell read a
paper with this title. He referred first to the close relation ex-
isting between the salivary organs and the genital organs of the
adult, as shown in mumps and other conditions. Parotid bubo
seemed particularly apt to follow ovariotomy where septicaemia
had taken place. He had seen parotid bubo once in 153 ovari-
otomies. This was in a greatly emaciated woman, from whom
a tumor weighing eighty pounds had been removed. The pa-
tient had been twice tapped ; once six weeks before the opera-
tion. The second tapping was followed by septic poison, and
the operation was performed as a last resort. The patient did
well until the ninth day. when the left parotid gland began to
swell. It suppurated and was opened. The patient finally died
on the twenty-second day after the operation.
There was a transference of irritation to the parotid glands
in which there was no evidence of septic poisoning. Of this
the author had seen three instances: twice after ovariotomy
and once after oophorectomy. In these cases the parotid com-
plication did not influence the progress of the case. Not one
of these ended fatally. He regarded the affection of the glands
as sympathetic and not symptomatic. Within a short time he
had operated on a lacerated cervix. The operation was followed
by free haemorrhage, and in the second week the parotid glands
began to swell. This was succeeded by hysterical trismus,
which lasted for some time. The patient recovered.
Dr. Sutton, out of twelve ovariotomies, had lost one patient,
and she died with the complication referred to in the paper.
The case did well until convalescence was reached, when one
parotid gland began to swell. This was followed by swelling of
the other gland. The temperature varied one or two degrees
from the normal. There was slight diarrhoea, but no tympany,
and no soreness. A number of rose-colored spots were found
about the second week over the abdomen and arm. In the
third week she became much worse. The glands diminished in
size, but the temperature ran up and she died. He considered
the case as septicaainic. Others considered it a well-marked in-
stance of typhoid fever.
Dr. J. Tabek Johnson, of Washington, had seen this com-
plication in one case of ovariotomy, the patient dying on the
sixth day.
Dr. Mann referred to three cases which he had seen. The
first was a case of ovariotomy. There were distinct symptoms
of septicaemia, and the patient died before the glands suppu-
rated. The second case was one in w'hich he had removed al]
the uterus above the internal os, and also the ovaries. At the
Oct. 3, 1885.]
PROCEEDINGS
OF SOCIETIES.
387
end of the first week one gland became swollen. There was
little fever. The patient made a good recovery. The third
case was that of a boy who'had received a penetrating wound
of the abdomen. Enlargement of the glands followed, but he
made a good recovery.
Dr. Emmet added two cases. Once the condition followed
an operation for lacerated cervix, the patient recovering. Once
it followed an operation on a small vesico- vaginal fistula, the
patient dying.
Dr. Baker had seen the complication follow T ait's operation,
but the patient recovered.
Dr. Reamy had had two cases, one after Tait's operation.
The patient died the seventh day after operation. The second
was a case of supra- vaginal hysterectomy in which the uterus
and both ovaries were removed. The left gland became much
enlarged, but did not suppurate. The patient recovered.
Peristalsis of the Genital Tract, and a New Theory to
explain Relaxation of the Vaginal Outlet during Labor.—
Dr. James R. Chadwick, of Boston, read a paper with this title.
Some time ago the speaker was called to see a primipara in
labor. He found the os slightly dilated and the vaginal outlet
quite rigid. Returning two hours later, be found the outlet
much relaxed, although the head had not escaped from the
uterus. On another occasion a woman with a bleeding fibroid
tumor consulted him. The examination revealed quite a small
outlet. Ergot was given to check the bleeding. After that the
outlet was found much relaxed ; this had occurred coincidently
with the occurrence of uterine contractions and the forcing
down of the tumor. Further investigation of this subject had
led him to the conclusion that there was a peristaltic action of
the lower portion of the genital canal as well as of the Fallopian
tubes, and that it was to this that the relaxation of the outlet
was largely due.
Facial Paralysis in the Infant from the Use of the Ob-
stetric Forceps.— Dr. Theophilus Parvin, of Philadelphia,
read a paper on this subject. The following case was described :
A well-proportioned woman, aged thirty years, had been in labor
thirty-two hours, the first stage lasting twenty-four hours. The
only difficulty appeared to be want of strength in the uterine
contractions. The forceps was therefore applied, and the child
extracted. The following day it was observed that one side of
the face was paralyzed. This was especially noticeable when
the child cried. There was no evidence of bruising from the
forceps. The paralysis disappeared in ten days without treat-
ment. The literature of this affection was then summarized.
Dr. Ellwood Wilson had met with this accident a number
of times. Recovery, as a rule, bad occurred spontaneously.
Dr. Goodell had seen such cases, and in every instance the
paralysis had been on the right side. He attributed this to the
predominance of the left occipito-anterior and the right occi-
pito-posterior positions. Under such circumstances, one blade
of the forceps would make pressure on the nerve.
Dr. Skene considered the differential diagnosis between
facial paralysis from injury and facial paralysis from apoplexy
to be of importance. Usually the diagnosis was readily made,
but difficulty occurred when there was facial paralysis from
injury, associated with paralysis of the arm caused by violence
in delivery. He had recently seen such a case in consultation.
In this case it was of great importance to complete the labor
quickly, and the shoulder had been injured in delivery, so that
there were facial paralysis and paralysis of the arm on the same
side. At first there was no trace of contusion, but in a short
time ecchymosis appeared and a favorable prognosis was given,
which was verified.
Dr. W. L. Richardson, of Boston, said that in most of the
cases he had seen the paralysis had been on the right side. It
sometimes occurred where the forceps was applied to the after-
coming head.
The following papers were read by title: " The Genu-Pec-
toral Posture in the Prolonged Nausea and Vomiting of Preg-
nancy, with Cases," by Dr. II. F. Campbell, Augusta, Ga. ; "A
Study of an Unusual Type of Puerperal Fever," by Dr. Fordyce
Barker, of New York.
A resolution expressing the sympathy of the society with
Dr. Albert H. Smith, of Philadelphia, in his sickness, was offered
and adopted.
PATHOLOGICAL SOCIETY OF PHILADELPHIA.
Meeting of September 10, 1885.
The Vice-President, Dr. J. Henry C. Simes, in the Chair.
Secondary Epithelioma.— Dr. George Dock exhibited to
the society a patient suffering from this disease and related the
following history:
The case occurred in the practice of Dr. W. W. Keen, at St.
Mary's Hospital, to whom Dr. Dock acknowledged his indebted-
ness for the opportunity of recording it.
Mary C, aged seventy years, married, born in Ireland, ap-
plied for treatment November 29, 1884. Her personal and
family histories seemed to be unusually good. No traces of
constitutional disease could be found. She used alcoholic liquors
in moderation, and had smoked a clay pipe for the greater
part of her life. Filling the right submaxillary region and ex-
tending up over the inferior maxilla was a tumor, the distinct
outlines of which included a space about three inches in diame-
ter. The lower part was very prominent, standing out as a
flattened node one inch and a half in diameter and about three
fourths of an inch high, the whole height of the tumor being
one inch and a half. The growth was hard and immovable on
the lower jaw ; the surface was smooth and red, changing to a
dull purple on the nodular elevation. On the summit of this
growth was an opening leading upward and inward three quar-
ters of an inch. The skin around the opening was everted and
the surface of the crater-like cavity was covered with large and
small granulations which exuded a thin, gray, offensive pus.
The neighboring lymph-glands were not enlarged. The general
condition was good.
The patient stated that the growth first appeared, six months
before admission to the hospital, as a " kernel " below the jaw.
She applied various poultices and salves to it. The tumor grew
rapidly for the following four months, when it opened, discharg-
ing a large amount of pus; after that there was no apparent
increase in size. The patient could assign no cause for the
tumor except a scald, received about one year before on the
lower lip near the angle of the mouth on the right side. This
was followed by an ulcer, which was removed at the Episcopal
Hospital in February, 1884, about two months before the ap-
pearance of the enlarged gland. Dr. J. M. Bradford, late resi-
dent physician at the Episcopal Hospital, stated that the ulcer
was noted as epithelioma.
On December 3, 1884, Dr. Keen removed the tumor, together
with a margin of healthy skin and the submaxillary salivary
gland. The external plate of the inferior maxillary appearing
roughened, it was cut away. The cavity of the mouth was not
opened. By the use of hare-lip pins and sutures, the edges of
the large wound, four inches and a half in diameter, were ap-
proximated almost perfectly. The dressings at first were car-
bolized ; afterward iodoform was used. In the fourth week
after the operation a small, red, indurated, sometimes painful
spot appeared in the skin just posterior to the wound. A few
days later the patient was discharged.
Microscopic sections, made through various parts of the
388
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jodb.,
growth, showed the structure of squamous epithelioma every-
where. The salivary gland was invaded. No trace of the
lymph-gland could be found, and the supposition was that it
had ulcerated away completely.
The patient was lost sight of until the beginning of May,
1885. She stated that after leaving the hospital the small
swelling alluded to increased rapidly in size, and in a few weeks
was larger than the one removed. She used no irritating meas-
ures, but the tumor broke down and ulcerated away, leaving a
large granulating surface. Examination revealed an ulcer on
the side of the neck extending from one inch to the right of the
median line to beyond the angle of the jaw, irregularly circular
in outline and containing islands of epithelium. There was a
small opening into the cavity of the month midway between
the angle and the symphysis of the jaw and just inside of the
inferior border of that bone. The symphysis was drawn to the
right about half an inch. There was a hard, tender swelling on
the gum above the inner edge of the opening, covered with
small, dark-red nodules. In June the inferior maxilla was still
more atrophied and had separated at the point of swelling and
opening before mentioned. The adjacent ends of bone and
gum were covered with a small fungous growth.
The process of atrophy and new growth is still continuing.
The left alveolar process approaches the median line of the oral
cavity, and the point of the chin is on a line dropped from the
outer angle of the right eye. The ulcer on the neck is healing,
but the new growth in the mouth is rapidly enlarging, so that
the tongue can not be extruded. There are no eidarged lymph-
glands, but within a few days the patient has complained of
pain in a gland in the subclavian region. The general condition
is very poor; the patient lives on liquid food and takes morphia
to produce sleep.
An Enlarged Prostate. — Dr. Gut Hinsdale exhibited a
specimen which had recently been presented to the Mutter Mu-
seum of the College of Physicians by Dr. J. L. Stewart, of Erie,
Pa., and was removed from a man aged seventy-five years, who,
sixteen years previously, had first come under Dr. Stewart's
observation.
At that time he was a strong, well-developed man, who had
never been sick before in his life, but was then suffering from
retention of urine, which had existed for seventy-two hours-
It was found to be impossible to introduce a catheter, owing to
an enlarged prostate estimated to be larger than a hen's egg.
Circumstances rendered it necessary to force an instrument
through the gland, and five pounds and a half of urine were
drawn off. A train of most unpleasant symptoms followed, and
for weeks there was profuse suppuration with complete incon-
tinence and great prostration. After about thirty days, improve-
ment began and continued to complete recovery. Three months
afterward the patient seemed perfectly well.
Attacks of cystitis and retention became frequent, and for
sixteen years only once did an interval of over three months
pass without an attack, the usual time being about twenty days.
During this time Dr. Stewart introduced the catheter 1,194
times. Pain was intense during the later years, when four or
five ounces of urine had collected in the bladder. Meantime
the prostate continued to increase in size, and in November,
1884, was believed to be of the size of a large orange. On the
night of the 27th of May, 1885, the patient had his last attack.
Dr. Stewart not being at hand, two other physicians did not
succeed in introducing an instrument. Just before 9 a. m. of
the following day the man was attacked with the most excruci-
ating pain, followed by a severe chill. At this time it is be-
lieved by his medical attendants that rupture of the bladder
occurred, and the early date of this accident was accounted for
as being the result of the contracted condition of the bladder.
From this time there was no acute pain, but there was a severe
aching followed by prostration. At 9.30 a. m. the bladder was
aspirated, one ounce of urine coming away. Dr. Stewart cathe-
terized him on the third day, drawing about a tablespoonful of
urine. The patient died on the morning of the fourth day. His
mind was clear and his voice strong to the last.
The post-mortem examination was not made by Dr. Stewart
personally. It was stated that there was a rupture of the ante-
rior part of the bladder near the fundus, and that the cavity of
the abdomen was filled with urine. The specimens were not
removed in such a way as to make this evident.
The specimen, as presented, consisted of the prostate gland
laid open by a cut in the vertical line and having attached to it
the bladder, the walls of which had been cut in several direc-
tions. These walls were thick and had apparently undergone
fatty degeneration, as had also the kidneys which accompanied
the specimen, the pelves of which were thickly overlaid with
fat. The long diameter of the prostate, after being in alcohol
for three months, was three inches; the shorter diameter two
inches and three quarters; the third lobe was one inch long, and
through it the catheter passed and still remained in position.
The bladder-walls, when replaced, indicated a very small inter-
nal capacity.
Dr. J. M. Barton stated that but one case of rupture of the
bladder from over-distension had come under his observation.
It occurred in a German, who had an impermeable stricture of
eight years' duration; no urine whatever passed; the contents
of the bladder were removed several times by aspiration, while
attempts were being made with filiform and other bougies to
pass the stricture. As these failed, perineal section was sug-
gested to the patient and his friends, but refused, and the doc-
tor was told that they would send for him when they needed
him. Three days later Dr. Barton was sent for; he proceeded
to the house accompanied by Dr. S. W. Gross. The man was
in a dying condition ; the bladder tumor, which before was very
prominent, had disappeared. Aspiration over the pubes, and a
trocar inserted by way of the rectum, both failed to reach any
urine.
On post-mortem examination, a small rent was found in the
upper part of the bladder, but the specimen could not be se-
cured.
In old cases of prostatic obstruction Dr. Barton had several
times found, on post-mortem examination, that the patient had
thrust the instrument through the "third" lobe; in one case
several such openings had been made and had kindly healed.
Cancer of the Stomach.— The Committee on Morbid
Growths reported regarding Dr. Mitchell's specimen, exhibited
at the last meeting in June, as follows :
(a) Stomach. — Microscopic sections across the wall of the
stomach showed an active proliferation of the epithelium of the
mucous membrane, pushing its way into the wall, infiltrating it,
and forming alveolar spaces. The wall was further infiltrated
with young cells, which, for the most part, replaced the normal
structure of the part. The process had probably been a chronic
catarrh with great hypertrophy, passing gradually into a carci-
nomatous type.
(&) Omental Nodules. — Sections of these showed an indis-
tinct alveolar structure filled with epithelial cells, and a small-
celled infiltration of the adipose tissue. The appearances were
those of a carcinoma, secondary, probably, to the growth in
the stomach.
Hsematocele of the Testicle.— The committee reported re-
garding Dr. Nancrede's specimen as follows :
Sections exhibited layers of more or less well-developed con-
nective tissue, through which were scattered numerous young
connective-tissue cells. No evidence of sarcoma tissue was
Oct. 3, 1885.]
MISCELLANY.
389
present. The growth should be classed as a chronic connective-
tissue hypertrophy, and, as the sac contained blood, the speci-
men was of chronic hematocele.
The International Medical Congress. — In addition to those hereto-
fore mentioned in our columns, the following-named appointees are said
to have declined to hold office under the new organization : President
Gilman, of the Johns Hopkins University ; Dr. E. Fletcher Ingals, of
Chicago ; and Dr. E. G. Loring, of New York.
The " Medical News " publishes the following resolutions lately
passed by the Chester County, Pa., Medical Society:
" Whereas, The members of this society feel a lively interest in the
prosperity of the American Medical Association and in the highest suc-
cess of the Ninth International Medical Congress, and believe that when
a mistake has been made it is better to correct it than to ignore it
through a false pride of consistency ; therefore
" Resolved, That it is the judgment of this society that, while the
American Medical Association has a perfect right to enforce its code of
ethics upon all associations subordinate to it, it has no such right as
regards the International Medical Congress, a body with which it has
no fixed connection and which does not undertake to regulate matters
of professional ethics. That the attempt to organize the Congress
solely from its own membership and that of subordinate associations
was most unwise and inhospitable, and calculated to lessen the influ-
ence and usefulness of the American Medical Association.
" Resolved, That we hereby instruct our delegates to the next an-
nual meeting of the American Medical Association to use all honorable
endeavors to secure that the false step taken at New Orleans shall be
retracted, and that those who led the association into the present follv
shall not be intrusted with the arrangements for the International
Medical Congress."
The " Louisville Medical News " says :
" On another page we quote from the Congress committee's author-
ized report the more important items of its doings at the recent called
meeting in New York city. A careful inspection of the report shows
that beyond a liberal alteration of the rule of membership, the separa-
tion of gynaecology from obstetrics, and the restoration of the section
of dental and oral surgery to the place assigned it by the original com-
mittee, with fit elaboration of the rule relating to finances, no essential
changes are made in the scheme of organization. The chief work of
the committee seems to have been the re-arrangement of the lists of
officers, committees, and councilmen, and the filling of the many gaps
in the ranks made by the withdrawal of those who declined to serve
under the new leaders.
" No concession was made to the wishes of the distinguished seced-
ers and their many supporters among the profession at large, unless
the retention of the name of Dr. Bowditch upon the list of vice-presi-
dents be so construed. The only concession upon the other side was
offered by Dr. S. C. Gordon, of Maine. This gentleman repented of his
sin against the new committee, and, after confession, was graciously
received and forgiven, but not conducted to a higher seat in the syna-
gogue.
"It will also be noticed that the opinions of certain distinguished
foreigners with reference to the committee's office and work were
ignored in toto, not being accorded even the courtesy of a polite remon-
strance. The committee has doubtless done just the work its manipu-
lators set to its hands ; but, whether its policy be voted wise or foolish,
the denouement will show that the breach between the opposing parties
is widened beyond repair, and that the contending voices are dissonant
beyond the hope of harmony.
" The distinguished guests who, soon after the June house-warming,
stepped out and have since been standing in the rain, have not been
asked to come in by the new proprietors ; nor would they in the exist-
ing state of the house have accepted the invitation had it been ex-
tended. Their places have been or soon will be filled by others,
worthy, indeed, but less renowned ; and when the new list of officers
and councilmen for the Ninth International Medical Congress shall be
laid before the medical world, it will be destitute of many attractive
features which characterized the original committee's issue in the early
spring. Whether or not this strangely altered face will have charms
of sufficient attractiveness to draw our foreign brethren across the sea
remains to be seen ; but, if the signs of the times be not grossly mis-
leading, the Congress of 188V will not meet on American soil."
" The Journal of the American Medical Association " says : " Per-
haps the action of no organized body of men was ever before so exten-
sively and persistently misrepresented as that of the American Medical
Association at its meeting in New Orleans regarding the preliminary
organization of the International Medical Congress of 1887. Instead
of wasting time and space in enumerating and refuting these misrepre-
sentations in detail, we will oppose to them all the following simple
statement of historical facts :
"1. At the preceding annual meeting in Washington, May, 1884,
on the recommendation of the president, Prof. Austin Flint, of New
York, indorsed by the report of a special committee, of which Dr. J. S.
Billings, of Washington, I. Minis Hays, of Philadelphia, and Lewis A-
Sayre, of New York, were members, the association was induced to
adopt resolutions presented by said special committee, authorizing the
president of the association to appoint a committee of seven, of which
he should be a member, which committee should attend the Interna-
tional Medical Congress to be held a few months later in Copenhagen,
and in behalf of the profession of the United States extend an invitation
for the next triennial meeting to be held in this country. If the invi-
tation was accepted, the same series of resolutions conferred upon the
same committee authority to add to its number and exercise all the
powers of a committee of arrangements for effecting the preliminary
organization of the proposed Congress, with an appropriation from the
treasury of the association to defray necessary preliminary expenses.
The committee thus authorized was appointed by the president and
consisted of Dr. J. S. Billings, Dr. Austin Flint (ex-offieio), Dr. I. Minis
Hays, Dr. J. M. Browne, Dr. L. A. Sayre, Dr. Christopher Johnson, Dr.
S. J. Engelmann, to which was added Dr. H. F. Campbell as president-
elect of the association. The fact that this Committee of Invitation
had been appointed by the American Medical Association, which by
such appointment had made itself responsible for the acts of such com-
mittee in carrying out the instructions contained in the resolutions, was
published in all the leading medical journals, and could not have been
otherwise than well known in Europe. In due time the invitation was
extended by the committee and formally accepted in open session of
the Congress in Copenhagen. The committee returned home, invited
sixteen other prominent members of the profession to unite with them,
constituting a General Committee of twenty-five. This General Com-
mittee held one meeting in Washington, organized by the election of a
president, vice-president, secretary-general, and treasurer. Rules were
also adopted for the organization of the Congress, one of which made
the officers of the committee also the general officers of the preliminary
organization of the Congress. At the same meeting some of the offi-
cers of sections were appointed, and further details of the work were
committed to an Executive Committee of five, subject to the approval
of the General Committee. The Executive Committee, by conferences
of its own and by correspondence with other members, so far completed
the work of organization as to publish the results both in this country
and Europe only a few weeks before the annual meeting of the asso-
ciation in New Orleans, the last week in April, 1885.
" 2. At the meeting of the association in New Orleans, Dr. J. S.
Billings, as the secretary-general of the proposed Congress, made a
brief report of the doings of the committee and presented a. printed
copy of the rules and official organization adopted. The report was re-
ceived and made the special order for consideration the following day.
At the hour appointed, several members freely criticised the work of
the committee, pointing out the fact that it had appropriated all the
chief offices of the Congress to its own members, that it had centered
an unduly large proportion of the officers of sections in two or three
cities, instead of making them representative of the profession of the
United States, in whose name the invitation had been given, and had
given undue prominence to a particular portion of the profession in
390
MISCELLANY.
[N. Y. Mud. Jopr.,
New York, which was well known to have arrayed itself in opposition
to the State and national organizations of the profession generally.
The result of the discussion was the adoption of two resolutions by the
association, both of which have been repeatedly published in the col-
umns of this journal, the effect of which was clearly to make the Com-
mittee on Organization more national in character, or, in other words,
more directly representative of the profession of the United States, by
adding to the original committee of eight, one from the profession of
each State and Territory, in the place of the additions previously made
by the original committee, and to give the committee thus enlarged au-
thority to review the work previously done by the Committee on Organi-
zation, and make such changes as the enlarged committee might think
advisable. This was the sum total of the action of the American Medi-
cal Association concerning the organization of the Congress. The reso-
lutions adopted contain not one word about codes of ethics, they dis-
place no one of the original committee, they prescribe no rule either for
the membership, government, or officering of the Congress, but simply
enlarge the original committee in such a way as to make it more repre-
sentative of the whole profession, and continue in the enlarged com-
mittee the same powers, substantially, as were conferred upon the
original committee at the meeting in Washington.
" 3. The committee as enlarged by the action of the association in
New Orleans held its first meeting in Chicago, June 24 and 25, 1885,
and organized simply as a committee of arrangements, its officers hav-
ing no corresponding positions in the proposed Congress, as had been
the case with the first organization of the committee. After as full an
examination of the work previously done as the time would permit, the
committee re-adopted nearly all the rules previously devised except those
relating to the American membership and the Executive Committee of
the Congress. The first of these it was proposed to amend in such a
way as to unnecessarily restrict the membership, and all provision for
the latter was overlooked. In consequence of these defects, the proper
work of the committee was continued, and a second general meeting
held in New York, September 3 and 4, 1885, during which the revision
of the rules was completed, the vacancies in the general offices of the
preliminary organization of the Congress filled, and an executive com-
mittee provided for, consisting of the president of the Congress, the
secretary-general, the treasurer, the chairman of the finance committee,
and the presidents of the several sections. The Committee of Arrange-
ments thus deliberately completed the work assigned to it by the asso-
ciation, and delegated to the Executive Committee of the Congress full
power to fill all future vacancies, complete all unfinished details of or-
ganization, increase to a limited extent the number of its own members,
and manage all the affairs of the Congress in accordance with the rules
adopted, without other restraint or interference from any source. The
rules in detail, together with the general officers of the Congress, the
presidents of sections, and the Executive Committee, were published in
this journal for September 12, 1885.
" We have given the foregoing plain narrative of facts regarding
the action of the American Medical Association and its Committee of
Arrangements for providing a preliminary organization for the Inter-
national Medical Congress of 1887, which would fairly represent the
medical profession of the United States, and under rules as liberal, in
relation to membership and in all other respects, as those adopted by
previous Congresses, to show, first, how utterly groundless have been
the charges and denunciations so persistently hurled at the association
and its committee ; and, second, that, notwithstanding all the persistent
opposition of a few prominent members of the profession having con-
trol of three or four leading medical journals, the association, through
its enlarged and representative committee, has fulfilled the obligations
it incurred in inviting the Congress to hold its next meeting in the City
of Washington in 1887, by effecting a preliminary organization on a
national and liberal basis, with ample power to manage all the business
and scientific interests of the Congress as independently as the interests
of any previous Congress has been managed in Europe. The responsi-
bility is now with the new Executive Committee and the true friends of
the Congress everywhere. If the committee will take up its work
promptly and push it harmoniously, it will receive ample support both
at home and abroad, and the Congress will be as successful as the most
enthusiastic could desire."
The "Medical Times and Gazette" says:
"A few days after the earliest news of the danger threatening the
next International Medical Congress had been published in Europe
("Medical Times," July 11 and 18, 1885), the two most prominent offi-
cers of the London Congress, Sir James Paget and Sir William Mac-
Cormac, each wrote to an American friend to express their view of the
situation — a view which coincided in all particulars with that previously
given vent to in our columns. These letters were not merely an ex-
pression of individual opinion, but were the result of consultation with
several of the most influential members of the London Congress. Sir
James Paget, in giving his recollection of what took place at Copen-
hagen when the American invitation was accepted, writes : ' Certainly
it was not supposed that the Congress would be regulated with any
degree of exelusiveness by the members of one medical association,
however numerous, and I think it quite as certain that, if this had been
thought possible, the proposal that the next meeting should be held in
the United States would not have been adopted.' ' I am sorry, also,'
he adds, ' to feel sure that, if the Congress be not supported by the
eminent men who have now declared that they will take no pail in it,
the members of the profession in this country who attend it will be
very few.' Sir William MacCormac, in his account of what happened
at Copenhagen, says : ' I am sure it was present to the mind of every
one there that the invitation was one from the profession of America,
and not from any section of it, or any particular medical society in it.
Otherwise, I feel pretty certain Prof. Virchow's invitation to meet on
the next occasion in Berlin would have been accepted.' In our last
issue we published what may, we suppose, be called the official reply to
Sir W. MacCormac's letter. In it, Dr. Davis, the editor of the ' Journal
of the American Medical Association,' censures with some bitterness
those Americans who have 'a morbid tendency to hang their laundry on
the front street,' and complains that so much attention should have
been given to 'this little misunderstanding' by European medical jour-
nals. Possibly some of the readers of those journals may sympathize
with that complaint, but, as the welfare of the next International Medi-
cal Congress is not a matter solely of American interest, it seems to us
to have been the bounden duty of individual men in Europe, and of the
European medical press generally, to point out to what extent the or-
ganizers of the Washington Congress were departing from the estab-
lished precedent, which, at any rate, has the argument of unbroken
success in its favor. Dr. Davis complains that 'the outside world'
animadverted on the conduct of the American Medical Association
before hearing both sides of the question. It may be replied to that
complaint, first, that the action of the association in disregarding the
precedent of previous congresses, and monopolizing the conduct of the
Washington meeting, was in itself a sufficiently accomplished fact to
warrant any amount of European animadversion ; secondly, that the
subsequent action and arguments of the supporters of the association
have served rather to weaken than to strengthen their case ; and, third-
ly, that it may be fairly assumed that the publication of European criti-
cisms has had a measurable share in determining the new Committee of
Organization to reconsider the whole question at issue during the pres-
ent month, instead of deferring it, as originally intended, until next
spring.
"We may remind our readers that two main objections have been
raised to the action of the American association — first, that, contrary
to precedent, the association put itself forward as the sole and exclu-
sive organizer of the Congress ; and, secondly, that, equally contrary to
precedent, it determined that only its own members, or delegates from
the societies in affiliation with it, should be allowed to take part in the
Congress. We are glad to hear that the latter objection has been
founded on a misconception, and that the conditions of membership
were still under consideration, and were not to be finally settled until
the 3d of this month. We hoped to have been able to give our readers
information as to the result of the meeting at which this point was to
come on for consideration, but up to the time of going to press we have
received no report of the proceedings. We trust, however, that the
more liberal views which have governed the admission of members at
previous congresses will have prevailed, and, if so, it may, we think, be
safely claimed that the opportune advice of Sir James Paget, Sir William
MacCormac, and the European journals has had some share in the result.
Oct. 3, 1885.|
MISCELLANY.
391
" But the objection still remains that the American association, in
taking charge of the Washington Congress, has introduced an inno-
vation in the conduct of International Medical Congresses which is dis-
tinctly a matter for international criticism, and, in our deliberate opin-
ion, for international condemnation. One of the most representative
medical men in the United States, who had been looked to by the new
Committee of Organization as a possible successor to Dr. Billings in the
office of Secretary-General of the Congress, Dr. Packard, of Philadel-
phia, has stated it as his conviction ' that it is contrary to all precedent
for the American Medical Association to assume any control of the
management of the Congress, which is a body by itself, and the mem-
bers of which will be in no sense the guests of the association, or sub-
ject to it.' ' Were I Secretary-General of the Congress,' he adds, ' 1
should not consider myself the appointee of the American Medical As-
sociation, nor responsible to it in any degree.' We believe that all the
officers of past congresses will fully sympathize with Dr. Packard in
this candid expression of opinion, even though it implies the con-
demnation of the action of the original organizing committee which
first raised the whole question and gave itself over, bound hand and
foot, to the American Medical Association, by admitting its responsi-
bility to it. That the original committee acted with great lack of judg-
ment, first, by a too lavish distribution of offices among themselves, and
secondly by reporting to the association, is now, we believe, generally
admitted. On this technical point no doubt the advocates of the asso-
ciation have the best of the argument. But they have as yet proved
no vestige of a right on the part of the association to break through the
rule of previous congresses, and to assume the sole management of the
Congress of 1887. Dr. Davis's argument, that 'as there is only one
body in England representative of the whole English or British profes-
sion, the British Medical Association, so there is only one in the United
States which could under any possible circumstances represent the pro-
fession in the United States, viz., the American Medical Association,'
is ludicrous rather than convincing to the English or British reader,
especially when the wise self-effacement of our own association at the
time of the London Congress is borne in mind.
" But the further action of the American association proves better
than anything how wise has been the precedent of previous congresses,
and how ill-advised the attempt to break through it. One of the first
acts of the American Medical Association, when it got hold of the Con-
gress, was to insist that only those in accord with the National Code of
Ethics should become officers of the Washington meeting, and, as a
result of this, many practitioners whose names are household words to
us, and who are described by Dr. Noyes in a published letter as 'the
brightest fights and best workers in the profession,' have been expelled
from all official connection with the Congress. By that action the
association at once broke the pledge deliberately given at Copenhagen,
relit the old-code dispute, and attempted to score a point against the
* new-coders' by enlisting against them the European visitors to the
Congress. The full and final results of this policy have yet to be seen,
but its first fruits, in the form of an electioneering manifesto published
by the association and sent to us by its representative, Dr. Shoemaker,
are not particularly reassuring. This manifesto is headed, more Ameri-
cano, 1 Pennsylvania sustains the Code of Ethics,' and then follows
a long list of practitioners in that State, all of whom profess to heartily
indorse the action of the association in raising the code question. We
need hardly add that this single official leaflet will do more to deter
respectable English practitioners from taking part in the Washington
Congress than all ' the statements of certain medical journals and pri-
vate parties in Philadelphia and New York,' of which Dr. Davis so
bitterly complains in his letter to Sir W. MacCormac. In our opinion,
the time has now come for the officers of past International Medical
Congresses to meet together and decide that, unless the pledge given
at Copenhagen is kept, and all attempts to embroil the Congress in
ethical disputes are unconditionally given up, the acceptance of the in-
vitation to meet at Washington should be rescinded, and arrangements
made to hold the Congress of 1887 in a country where the medical pro-
fession possesses greater solidarity."
The "Medical Times and Gazette," of London, publishes the fol-
lowing letter addressed by Dr. N. S. Davis to Sir William MacCormac :
" Having just read in the ' Boston Medical and Surgical Journal,'
of August 13th, your letter to Dr. J. Collins Warren regarding the In-
ternational Medical Congress, I feel that it is incumbent upon me to
reply to it personally, not only on the part of the medical profession
of the United States, but also on the part of the American Medical
Association ; and also on account of your manifest misapprehension of
the 'serious disagreement' of which you speak in your letter. Im-
primis, I will say that everything that has as yet been said by the Eu-
ropean press generally, and by the letters of individual men in Europe,
bears the evidence of misapprehension and misinformation. Our for-
eign confreres have accepted, unreservedly, the statements of certain
medical journals and private parties in Philadelphia and New York,
who from the very first of this little misunderstanding (which should
be a private affair until it is definitely settled in one way or the other)
have endeavored to obstruct the Committee of Arrangements for the
Ninth International Medical Congress. I have said that it should be a
private affair until it is definitely settled. It is unfortunate that some
Americans have a morbid tendency to hang their laundry on the front
street, where each passer-by may tell at a glance the character and ex-
tent of his neighbor's wardrobe. But still, it ill becomes his neighbor
to tell it to the world ; still less does it become the outside world to
animadvert on it before hearing both sides of the question. The pro-
fession in Europe seem to have heard of this matter from one side
only, and, without being conversant with the facts, have hastily jumped
to very illogical conclusions. As there is only one body in England
representative of the whole English or British profession — the British
Medical Association — so there is only one in the United States which
could, under any possible circumstances, represent the profession in
the United States — and that is the American Medical Association.
From Maine to California, and from the British possessions on the
north to Mexico on the south, every State and Territory is represented
in that body. Now, you say in your letter that you are ' sure that it
was present to the mind of every one there (Copenhagen) that the in-
vitation (to have the Congress meet in Washington in 1887) was one
from the profession of America, and not from any section of it, or anv
particular medical society in it.' To which it may be replied : The in-
vitation was extended by Dr. Billings, and Dr. Billings had been ap-
pointed to extend the invitation. Who appointed him V Whence came
his authority for assuring the Congress that it would receive a warm
welcome in this country in 1887? He was one of a committee ap-
pointed at a meeting of the American Medical Association, by the presi-
dent of the association, who acted for the association, and by the au-
thority of the association. And the necessary funds for enabling this
committee to perform their work were voted to it by the association ;
and they drew upon the treasurer of the association for the money.
Further than this, the committee was known and recognized as the
Committee of the American Medical Association on the Organization
of the Ninth International Medical Congress. They themselves recog-
nized the fact that they were the Committee of the American Medical
Association, else why should they have reported to the association at
its last meeting, in April, 1885 ? Can any one imagine a body of sane
men reporting to another body to which they owe nothing, and to which
they are in no way amenable ? Yet, when the creator of that commit-
tee— the body to which it owed its very existence — saw fit, on just
grounds, to revise a part of their work and to appoint additional mem-
bers to the committee to aid in such revision, they boldly say that the
association has nothing to do with it. The merest tyro in parliament-
ary law knows that the power which appoints a committee may refuse
to accept any of the work and appoint a new committee if it see fit.
That right is unquestionable, and unquestioned save by those who
know not whereof they speak. The American Medical Association has
invited the Congress to meet in Washington in 1887, and the invitation
has been accepted. The American Medical Association is fully compe-
tent to make all necessary arrangements for that meeting on as liberal a
basis as has characterized any of the preceding congresses. We onlv
ask that our brethren in Europe will reserve their comments until the
programme is completed and before them."
The editor of the " Times and Gazette " adds the following com-
ment: "We have not space in the present number to deal fully with
Dr. Davis's letter or with the other documents stating the case of the
American Medical Association which have reached us. We may, how-
392
ever, point out here that the British Medical Association has never
claimed to represent the whole English profession, though we believe
its claim to do so, if it should ever be so ill-advised as to make it,
would be much more valid than the claim put forward on behalf of the
American Medical Association. Whatever Dr. Davis may say, the fact
remains, as the officers of the London Congress have stated, that on no
previous occasion has any medical body attempted to capture and run
the International Congress as the American association is now attempt-
ing to do."
New York State Medical Association, — The first annual meeting of
the Fifth District Branch will be held in Brooklyn, at the Mansion
House, Hicks Street, at 11 a. m., on Tuesday, October 13, 1885. The
following papers are expected to be read : " Suggestions in regard to
the Causation and Treatment of Acute Coryza," by Dr. Austin Flint ;
"Further Observations on Diphtheria," by Dr. W. H. Thayer; "The
Physician and the Pharmacist — their Relative Duties," by Dr. J. P. Gar-
rish ; Report of a " Case of a Railroad Accident," by Dr. W. Govan ;
Remarks on " The Milk Supply of Large Cities and the Improper Mode
in which it is conducted," by Dr. H. A. Pooler ; " Progress of Electro-
lysis in Surgery," by Dr. Robert Newman.
The Brooklyn Pathological Society. — The following programme for
the season has been issued: October 8, 1885, "The Pathology of the
Inflammatory Process," by Daniel Ayres, M. D., LL. D. October 15,
1885, "The Pathology of the Inflammatory Process" (continued), by
Daniel Ayres, M. D., LL. D. October 22, 1885, "The Nervous Symp-
toms of So-called Lithaemia," by Landon Carter Gray, M. D. Novem-
ber 12, 1885, "Some Serious Sources of Error in studying the Course
of Disease," by Robert G. Eccles, M. D. December 10, 1885, " On the
Relations of Locomotor Ataxia to General Paresis," by E. C. Spitzka,
M. D. January 14, 1886, "On Diseases of the Brain resulting from
Affections of the Ear and Temporal Bone," by Arthur Mathewson, M. D.
January 28, 1886, " The Relation of Modern Dietetics to the Causation
of Disease," by E. H. Bartley, M. D. February 11, 1886, " The Role of
Tubercular Infection in the Development of Surgical Diseases," by
Lewis S. Pilcher, M. D. February 25, 1886, "On the Pathology of Sur-
gical Infection," by A. H. P. Leuf, M. D. March 11, 1886, "On the
Microscope in Diagnosis," by Frank Ferguson, M. D. March 25, 1886,
" The Effects of Diseases of the Nasal Passages on the Lower Respira-
tory Tract," by Thomas R. French, M. D. April 8, 1886, "The Pathol-
ogy of the Sympathetic Ganglia," by John C. Shaw, M. D. April 22,
1886, " On the Pathology of Tubercular Osteomyelitis, and its Bearing
upon Treatment," by George R. Fowler, M. D. April 29, 1886, "Some
Abnormalities of the Pulmonary Circulation," by Benjamin F. West-
brook, M. D. May 13, 1886, " The Pathology of the Lymphatic Glands
in Children," by Henry N. Read, M. D. June 10, 1886, " The Pathology
of the Puerperal Fevers," by Charles Jewett, M. D.
THERAPEUTICAL NOTES.
A Salicylate-of-Sodium Ointment.— Much of the efficacy of an unc-
tuous preparation of salicylate of sodium depends on the way in which
it is made. M. Pierre Vigier recommends the following method (" Gaz.
hebdom. de med. et de chir."):
Crystallized salicylate of sodium 2-J drachms;
Distilled water 75 grains :
Lard 10 drachms.
First spread the lard over the inside of a mortar, then dissolve the
salicylate in the water, and add the solution little by little to the lard,
triturating until the two are perfectly incorporated. The precaution of
first smearing the inside of the mortar with the lard does away with
the necessity of using oil of almonds, which otherwise is often found
necessary.
The Treatment of Pulmonary Gangrene with Inhalations of Car-
bolic Acid. — M. Constantin Paul (Ibid.) reports seven cases in which
this method of treatment was used with success. A one-to-seven wa-
tery solution is used in an inhaler so constructed as to insure the inha-
lation of all the vapor, while preventing the liquid from escaping. The
first effect is to arrest the putrefaction of the tissues. After the spha-
celated parts have been thrown off, the expectoration diminishes, factor
[N. Y. Mkd. Jors.
ceases, the appetite revives, and recovery may take place in less than
two months.
Euphorbia icterodoxa. — M. Landowsky (Ibid.) has studied the caus-
tic and destructive action of the juice of the Euplmrbia icterodoxa, a
plant that grows in the neighborhood of Peinambuco, and is vulgarly
called " alveloz." Although its caustic action is energetic, at the same
time it produces an analgesia comparable to that caused by cocaine.
The author has destroyed an epithelioma with it, but he failed in a case
of cancroid. Besides its escharotic action, the juice has a digestive
power like that of papain.
The Use of Tanghin in Nervous Diseases. — This ordeal poison of
Madagascar, derived from the apocynaceous tree variously named by
botanists Cerbera venenifera, C. rnauffhas, C. tanghin, Tanyhinia vene-
nifera, and T. venenijlua, has been made the subject of experiment by
M. C. E. Quinquaud (Ibid.). Its action on the central nervous system is
specially characterized by an exaltation of the hulbo-spinal reflex ac-
tivity. After a certain number of experiments on animals, M. Quin-
quaud administered an extract to man, in doses ranging between three
quarters of a grain and a grain and a half, in various diseases, notably
toxic paralyses, tremor, intestinal atony, and incontinence of urine.
Satisfactory effects were obtained, but only on condition that the use of
the drug was ceased as soon as the patients experienced headache,
nausea, vomiting, and a certain amount of debility.
A Substitute for Adonis Vernalis. — V. Cervello ("Annal. di Chim.
Med. -farm." ; " Ctrlbl. f. d. ges. Therap.") considers the Adonii cupa-
niana of the Sicilian coast as capable of replacing the A. vernalis as a
cardiac roborant in countries where the latter can not readily be ob-
tained.
Urethane as a Hypnotic. — Dr. von Jaksch (Wien. med. Bl.";
" Dtsch. Med.-Ztg.") describes urethane as the ethyl ether of carbamic
acid, NH2C02C2H5, a white, crystalline body, readily soluble in water,
odorless, and tasting like saltpeter. In doses of from four to fifteen
grains, it acts as a hypnotic, affecting chiefly the brain, without uotably
influencing the peripheral sensory apparatus ; hence it is not an ano-
dyne. Over all other pure hypnotics, however, it seems to have these
advantages: It is very well borne; it causes absolutely no complicating
effects ; and the sleep it produces resembles natural sleep in every re-
spect. The author thinks it will prove particularly serviceable among
children and in cases of delirium tremens and mania.
Lantanine as a Febrifuge. — This alkaloid, extracted by Negrete
from the verbenaceous plant Lantnna brasiliensis, is recommended by
Dr. E. Buiza, of Lima ("Cambio farmaceut." ; "Arch, de Med. y Cirug.
delosNinos"; "Courrier med."; " Nouveaux remedes"), as a substi-
tute for quinine. It retards the circulation and lowers the temperature,
and is tolerated by the most delicate stomachs. Intermittents that
have proved rebellious to quinine have yielded to thirty grains of lanta-
nine. As an antipyretic, it is given in doses of a grain and a half, from
ten to twenty of which are administered in twenty-four hours. For in-
termittent fever, it should be given immediately after a paroxysm, and
in ninety-five cases in a hundred the next paroxysm will not appear.
Ergotin in the Treatment of Landry's Paralysis. — Dr. Sorgenfrey,
a Russian physician (" Neurol. Ctrlbl." ; " Dtsch. Med.-Ztg."), relates
the case of a patieut, fifty-seven years old, who was attacked, about a
week after exposure of his back to a drenching rain, with a sensation
of heat, prostration, loss of appetite, and a sense of weight in the
lower limbs. Weakness in locomotion culminated in perfect paralysis
of all the limbs, dyspncea, impeded speech, dysphagia, etc. The sensi-
bility was normal. There was no pain. The cutaneous reflexes were
present, but the patellar reflex was absent. The urine was normal;
the bowels were constipated. No account is given of the electrical re-
action of the muscles. Leeches to the anus, dry and wet cups to the
lumbar region, cold compresses, and laxatives produced no effect, and
death seemed imminent. As a last resort, the following was ordered:
Bonjean's ergotin 19 grains;
Cinnamon water , 2 ounces.
A teaspoonful was given every hour, and the whole was used in the
course of a night. The next morning the bulbar svmptoms had disap-
peared, and within a week, without further medication, the patient was
well.
MIRGELLANY.
THE JSTEW YORK MEDICAL JOURNAL, October 10, 1885.
lectures a n t> 1 tr b r c s s e s .
LECTURES ON
ELECTRICITY IN MEDICINE,
DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI-
VERSITY OF VERMONT, BURLINGTON,
By AMBROSE L. RANNEY, M. D., New York.
(Concluded from page 28 4-)
ELECTRICITY IN DISEASES OF THE CERVICAL SYMPATHETIC,
THE VASO-MOTOR SYSTEM, AND ALLIED NEUROSES.
The cervical sympathetic is undoubtedly, in rare cases,
the seat of isolated morbid changes ; but, as Erb remarks,
these cases " constitute pathological curiosities." The mor-
bid conditions which have been detected embrace inflam-
mation, compression, traumatism, rheumatic conditions, etc.
Such conditions may create either irritation of the sympa-
thetic system or paralysis of its functions, or both simul-
taneously in different parts of the body.
Irritation of the cervical sympathetic produces pallor
of the face and neck upon the affected side, with a sense of
coldness in the parts. The pupils are dilated, the temporal
arteries exhibit increased tension, the power of accommoda-
tion and the reaction of the pupil to light are both impaired,
the eyeballs protrude slightly, and the secretion of sweat is
diminished.
Paralysis of the cervical sympathetic induces the oppo-
site conditions. The skin is red and hot, the patient suffers
from a sense of heat in the skin, the pupils are contracted
and exhibit normal reactions to light and accommodation
of vision ; the eyeball does not protrude, there are often
headache and vertigo, the secretion of tears and sweat is
increased, and the pulsation of the carotids is excessive.
In the electrical treatment of these opposed conditions
Erb recommends stabile applications of the anode (with a
strong current) until a change in the pupil is observed, if
the condition of irritation exists. The same author suggests
the use of the cathode with a feeble current, frequent in-
terruptions, and occasional reversal of the poles, if the
paralytic state is present. He places the "indifferent"
electrode upon the spine. He also suggests applications of
the wire-brush, or labile galvanic currents, to the skin of the
face and neck.
To the views of this author I would urge the advantage
of trying the effects of static insulation and sparks directed
to the neck and face.
Angioneuroses of the skin may assume one of two
forms, viz., spasm or paralysis. They are most frequently
observed in connection with neurasthenia and in hysterical
patients. The abnormal contraction or relaxation of the
vessels may cause (1) modifications in the color and the
general " feel " and sensibility of the skin ; (2) subjective
sensations of heat, tingling, formication, etc. ; (3) disturb-
ances of perspiration ; (4) awkwardness of movement of the
part (especially in the hands) ; and (5) many reflex symp-
toms referable to the viscera.
Unnatural conditions of the vessels of the skin (spasm
or paralysis) are most frequently observed in the upper
limb, less frequently in the lower limb, and least often in
the face and neck. They may be excited by a variety of
causes — such as fatigue, excitement, menstrual disturbances,
malaria, exposure to cold, the effects of poisons, and direct
irritation of the skin itself.
I have seen the skin (especially of the fingers) made as
white as chalk in some cases, and in others rendered cyano-
tic, by spasm of the vessels. The muscles of the papillae of
the skin may participate in the spasm and produce the so-
called " goose-flesh " appearance. Pain, tingling, formica-
tion, partial anaesthesia, and other disturbances of the sen-
sory apparatus may occur as sequehe to the vascular spasm.
Paralysis of the cutaneous vessels leads to directly oppo-
site conditions. The skin may be made intermittently or
permanently red, and feel unnaturally hot and extremely
sensitive. Subjects so afflicted frequently suffer from in-
somnia, headache, disturbed heart-action, excessive perspi-
ration, vertigo, and other visceral manifestations of irrita-
bility.
Respecting the electrical treatment of angiospasm and
angioparalysis, the general rule may be given that weak or
moderate applications of faradism or galvanism to the
affected part act best upon dilated vessels, and stronger
currents upon those affected with spasm.
Applications of static electricity are often very beneficial
to neurasthenic and hysterical subjects. Personally, I be-
lieve this method of treatment surpasses any other in its
effects upon this class, although it is well to alternate with
galvanism and faradism when a case proves obstinate to
treatment.
When any of the methods suggested are employed, it
is well to subject both the vaso-motor centers and the nerve-
trunks which supply the affected regions (as well as the
parts directly) to the influence of electrical currents.
neurasthenia.
By this term we mean the condition of nervous exhaus-
tion. It may be manifested in a variety of wavs. Its
symptoms will depend upon the type which exists — cere-
bral exhaustion or spinal exhaustion — and also upon special
idiosyncrasies peculiar to the patient. No two cases exhibit
identical manifestations of nervous depression. Some pa-
tients who are suffering from cerebral neurasthenia mani-
fest its effects in the voice, others in mental disturbances.
The heart's action may be alone disturbed in some cases,
the stomach may give out in others, some may complain
alone of muscular troubles, some may notice its effects in
the eyes, some are rendered sleepless, a few complain alone
of skin disturbances, and so on throughout the different
parts of the entire human organism.
You can understand how these apparently discordant
facts may be reconciled when you consider the fact that, by
means of the brain and spinal marrow and the nerves which
unite these centers to the different parts of the body, we
are enabled to see, hear, taste, smell, appreciate touch,
swallow, breathe, and perform voluntary muscular acts. It
is by means of our nerves alone that the heart beats ; the
394
RANNEY: LECTURES ON ELECTRICITY IN MEDICINE.
[N. Y. Med. Jodb.,
digestive processes go on, without our knowledge or con-
trol, through the same agencies ; the blood-vessels contract
and dilate in accordance with the demands for blood tele-
graphed to the nerve-center by different organs and tissues ;
and every process pertaining to life is thus automatically
regulated. Now it is easy to see at once how a debility of
so complicated an electric mechanism as the nerve-fibers
and the nerve-cells of a living animal are, can upset all or
any one of the individual functions enumerated. Many of
our houses are furnished to-day with electric bells by means
of wires distributed in the walls. In some houses we light
the gas-jets, and even the rooms themselves, by means of
the same subtle fluid. When the battery becomes weak, or
when the wires are disarranged or broken, what may be the
results ? Some of the bells may cease to ring when the
button is touched, while others work properly. Perhaps
the electric light may fail in some rooms and burn with its
accustomed brilliancy in others. The gas-jets may not be
properly ignited. So it is with the nervous apparatus of
man. From the same cause one patient may have nervous
dyspepsia, another sleeplessness, a third sexual debility, a
fourth weakness of the eye-muscles, a fifth disturbances of
the skin. It is needless to multiply illustrations.
Cerebral neurasthenia {brain exhaustion) may be
indicated by one or more of the following symptoms : Ten-
derness of the scalp ; pains in the head ; fleeting neural-
gias; sleeplessness ; vertigo ; a tenderness and pallor of the
gums ; abnormal sensitiveness of the teeth ; blanching of
the hair ; flushings of the face ; dilatation of the pupils ;
idiosyncrasies in regard to food and external irritation ;
mental depression and melancholia ; defects in memory ; a
morbid craving for alcohol ; a decrease in intellectual
capacity ; a buzzing or ringing in the ears ; specks before
the vision ; abnormal and imaginary impressions of taste or
smell ; morbid fears of various kinds ; sick headache ; dry-
ness of the skin and the mucous surfaces ; weakness of the
muscles ; numbness in the limbs ; thickness of speech ; and
mental excitability, irascibility, or loss of emotional con-
trol.
These symptoms, in many cases, are but the manifesta-
tions of weakness. The electric batteries of the brain (those
minute organs known as the " brain-cells ") are feeble or
uncertain in their action. They are incapable of perform-
ing the offices for which they were created. They are not
diseased (in a medical sense), but they are weak and liable
to become so sooner or later. I have known sufferers of
this type to be precipitated into a condition of incurability
by mental alarm, excited, in some instances, by an opinion
of an unfavorable kind made by physicians respecting a
prospect of recovery. Again, it is well known that insanity
may arise as a consequence of the loss of sleep often expe-
rienced by these subjects, and by " brooding over their
symptoms," whose significance they fail to properly under-
stand. I recall several cases where a patient was with diffi-
culty convinced that some special type of malady was not
about to attack him, because in reading a medical work his
attention had been called to the significance of some special
symptom which he was sure he had personally experienced.
If medical students, who possess vivid imaginations, can be-
come (as they often do) victims to imaginary diseases whose
symptoms they have been studying, is it to be wondered at
that the weak and highly organized sufferers from neuras-
thenia are especially prone to become impressed by tins
form of delusion?
Spinal neurasthenia (spinal exhaustion) signifies an
exhausted state of the cells which help to form the spinal
cord. The cord itself is of about the size of an ordinary lead-
pencil, and is sixteen inches in length (much shorter than
the backbone). It is composed of millions of nerve-cells
and distinct bundles of nerves. Some of these nerves pass
through it to reach the brain above, while others become
united to the spinal cells and pass no farther. The cells of
both the brain and spinal cord are practically electric bat-
teries; and the nerve-fibers are the wires by which they
are connected with the different organs of the body, the
muscles, skin, joints, and viscera. This wonderfully con-
structed organ is under the control of the brain, but is
capable of exerting, under certain circumstances, a control
over all acts which are termed " reflex acts," because they
are, to a greater or less extent, independent of the will. It
serves also as a means of conduction to the brain of our
perceptions of pain, temperature, and touch, and of motor
impulses sent out from the brain-cells to the muscles of the
limbs and body.
Now, when the cells of the spinal cord become exhaust-
ed, the symptoms produced differ markedly from those al-
ready mentioned as indicative of brain-exhaustion. Among
its chief manifestations *may be mentioned the following : A
general tenderness of the skin to touch or pressure; tender-
ness along the spine or over certain limited portions of the
spine ; irritability of the breasts, ovaries, and the womb in
females ; fleeting pains of a neuralgic type in various parts
of the body ; an extremely rapid or slow pulse, which fluc-
tuates widely during periods of excitement or fatigue ; at-
tacks of palpitation of the heart ; dryness of the skin, or in
many cases the reverse, excessive perspiration of the hands
and feet ; sudden startings on going to sleep ; muscular
twitchings in one muscle or a group of muscles ; chilliness
and creeping sensations along the spine ; numbness or
abnormal sensations of heat in the skin of the body or
limbs ; itching of the skin ; eruptions upon the skin, chiefly
of the type of eczema ; frequent gaping, yawning, or stretch-
ing; frequent seminal emissions; weakness of the bladder
and rectum ; and disturbances of the digestive functions.
The distinction between cerebral and spinal neurasthe-
nia which has been shown to exist can not be made in each
and every case, because various combinations of the symp-
toms of the two are often encountered in the same individ-
ual. A prominent author upon this type of diseases very
aptly compares the nervous system of man to certain moun-
tainous regions, since it causes so many echoes and rever-
berations. He says: "An irritation at one point may be
transferred to any other point, following the paths of least
resistance and making itself felt in those parts that are
least able to resist molecular disturbances. Thus, for exam-
ple, seminal emissions and spermatorrhoea, when they arise
through abuse or through spinal cord disease, almost uni-
formly react on the brain — robbing the sufferer of courage
Oct. 10, 1885.]
RAN NET: LECTURES ON ELECTRICITY IN MEDICINE.
395
and manliness, exciting various phases of morbid fear, of
which I shall speak, with aversion of the eyes and counte-
nance."
I have known a decayed tooth to cause persistent ear-
ache, and in one case to cause the corresponding eyebrow
to become white. In male children a tight foreskin not
infrequently creates sufficient irritation of the sexual organs
to induce spasms or paralysis of the lower limbs by an in-
direct effect upon the spinal cord. I have cured some pa-
tients, who have come to me for relief from persistent and
excruciating attacks of neuralgia, by a correction of some
defect in their eyes by means of glasses. The strain and
irritation produced upon the brain by the involuntary ef-
forts made by these patients to see objects with distinctness
or to read and write had reacted upon the nervous system ;
and it would have continued so to react till death if the
cause of the irritation had not been removed.
It may be well to consider a tew of the more prominent
manifestations of nervous exhaustion separately. Among
these, sleeplessness, a defect in vision known as asthenopia,
sexual weakness, headache, an unnatural dryness of the skin
and mucous surfaces or profuse sweating of the hands, and
morbid fears or melancholia, deserve special mention.
Insomnia. — Sleeplessness may assume different forms.
Some of those afflicted have difficulty in getting asleep ;
some awake after a few hours of slumber and remain so
until daylight ; a few find themselves overpowered with a
desire for sleep during their working hours, when their
business will not admit of it, and at night can not obtain
sleep except under narcotics. I have had patients who
have told me that they spent most of tbeir nights for years
in writing to friends, riding in the horse-cars, or walking
the streets for amusement because they could not sleep. It
is safe to assert that persistent insomnia, extending over a
period of weeks or months, indicates disease of some kind.
In patients who have passed the age of fifty, or in younger
persons who have indulged to excess in alcohol, it is often
due to a type of kidney disease, to detect which repeated
examinations of the urine are required. This form of
trouble is known as the "granular" or " contracted kid-
ney " ; and insomnia, frequently combined with headache,
is one of its most prominent symptoms. Obstinate sleep-
lessness is the cause of many a suicide, too often the start-
ing-point of the opium and chloral habit, and surely the
destroyer. I would caution you against allowing this symp-
tom to remain uncontrolled for any length of time, and to
avoid the use of all forms of narcotics as long as possible.
The chains of intemperance are but silken threads when
compared to those of the opium or chloral habit.
Asthenopia. — This type of defective vision can not be
relieved by ordinary glasses, nor does it respond quickly to
the customary suggestions of gymnastics, horseback-riding,
etc. It is due to a peculiar weakness of the muscles which
control the movements of the eyeballs, and it manifests it-
self chiefly as a sense of extreme weariness when the eyes
are steadily employed for short periods of time. It is an
indication of neurasthenia, and is of great diagnostic value.
In severe cases it becomes necessary to divide the tendons
of the stronger muscles of the eye, in order to relieve the
weaker ones of a strain. It is common among near-sighted
and far-sighted persons. I have seen patients who could
not sew for five minutes at a time from this cause, and
others who would be made sick by attending a theatre, pic-
ture gallery, or other places of amusement.
Headache. — Many attacks of this character are un-
doubtedly to be attributed to imprudences in eating, ex-
posure, or fatigue. But I believe that many of those who
are periodically afflicted in this way owe their suffering to
a lack of tone in the muscular coat of the blood-vessels of
the brain, consequent upon some of the causes of neuras-
thenia mentioned. I have seen a large number of instances
where the eyes were the cause of such headaches, and where
the adaptation of glasses has brought immediate relief.
The medical profession are rapidly becoming enlightened
upon this fruitful cause of pain. It is well also to examine
the urine when persistent or periodical headache occurs, as
it may be a symptom of kidney disease. Some neurolo-
gists believe that the so-called " sick headaches " are to be
regarded as but a modified form of that condition which
produces epilepsy. A volume might be written upon this
symptom alone.
Dryness or Unnatural Moisture of the Skin. —
Some nervous patients suffer from an unnatural dryness of
the skin, the throat, and the nose. They are also liable to
experience dyspeptic symptoms at the same time, which is
probably due to similar changes in the lining of the stom-
ach. This dryness may be accompanied also by an itching
of the affected parts or an attack of eczema. A burning
sensation is sometimes produced. I was once consulted by
a patient who had for years been in the habit of incasing
himself in flannel and putting on flannel stockings before
he retired, in order to overcome a sense of burning in the
skin which followed the contact of cotton or linen with any
part of his body. I recall a case where the feet were once
frost-bitten, and the patient has never since been able to
walk upon a carpeted floor on account of a burning sensa-
tion which immediately follows. He takes off his shoes as
the last step before retiring.
On the other hand, many patients afflicted with neuras-
thenia suffer from a profuse sweating of the palms of the
hands. This is accompanied in some instances by a flush-
ing and redness of the face, neck, and ears. The nails may
become unnaturally soft or brittle.
Morbid Fears. — This peculiar manifestation of nervous
exhaustion may assume one of several types. Attempts at
classification of these morbid fears have been made by some
authors, such as fear of lightning, of places, man and socie-
ty, solitude, accident, etc., and special names have been
applied by them to each of these types. Fears of this kind
may be present without any other manifestation of mental
impairment. They are usually uncontrollable, in spite of the
fact that the patient may exhibit a knowledge that they are
groundless and absurd. They seem to take full possession
of a being, and to cause mental torture of an extreme kind.
Finally, melancholia is not an infrequent symptom of
neurasthenia. It may be accompanied by paroxysms of
laughing, weeping, and hysterical phenomena.
Now, in the treatment of neurasthenia, electricity is one
396
MINOT: TEE EARLY STAGES OF HUMAN DEVELOPMENT. [N. Y. Med. Jouk.,
of our most effective agents. After the exciting cause has
been discovered and the possibility of its continuance re-
moved, we may safely begin the use of electricity with the
brightest prospect of a radical cure. General faradization,
central galvanization, and the use of franklinism are par-
ticularly of service. Of the latter I can speak in the high-
est terms. Neurasthenic patients often feel its beneficial
effects immediately. It should be applied daily by the in-
sulation method, the electric wind, or the static spark, as
the circumstances of the case seem to indicate.
My remarks made in a previous lecture respecting mass-
age and other adjuncts to electrical treatment Tire particu-
larly applicable to this class of patients. No effort should
be spared in your treatment to promote constitutional vigor
by exercise, judicious feeding, good hygienic surroundings,
and the like.
You, as physicians, will have to decide such matters for
yourselves, and advise your patients respecting them with
references to the symptoms which are to be combated.
Do not trust too implicitly in electricity alone (valuable as
it may be as a means of cure). Active employment will be
necessary to a cure in some cases ; absolute physical and
mental rest will aid in others ; some will require travel or a
change of surroundings ; the organs of the body will often
demand special attention with a view of properly regulating
their functions; and many other similar problems will have
to be decided before a cure can be predicted by the aid of
electrical agencies.
In bringing this course of lectures to a close, gentlemen,
I can not but feel that much has been, of necessity, Omitted
by me which would be of benefit to you. A more com-
plete course upon electro-physics, for example, would have
beeD given had I not felt that text-books on physics would
furnish you with the requisite knowledge when needed, and
that the time allotted by me to the consideration of elec-
tricity could be better spent in dealing with the practical
applications of this agent in the diagnosis and treatment of
disease. In these respects even this course is far from com-
plete. It is but a hasty sketch of the more important facts.
It is well for each of you to bear constantly in mind
that electricity as a therapeutical agent is yet in its infancy.
Facts are being daily brought to light, however, which will
aid us in employing it upon the sick to better advantage,
and in obtaining more uniform results. As fast as new
discoveries are published they will naturally be subjected to
tests by those laboring in this field, and, if their value is
proved, they will in time become generally recognized and
employed by the profession.
Perhaps some of this class of students may be among
the number who are destined to promote the growth of this
department of therapeutics by their inventive faculty, origi-
nal research, or clinical observation. I trust that it may
prove so.
If I have succeeded in awakening your interest suffi-
ciently to induce any of you to pursue this line of study
further with intelligence, and thus to give possible benefit
to others, I shall feel amply repaid for the many hours of
thought and manual labor that I have personally spent in
trying to modify and improve existing electrical appliances.
(Original Communications.
THE EAELY STAGES OF HUMAN
DEVELOPMENT.
By CHARLES SEDGWICK MINOT, M. D.,
BOSTON.
Part II. — Embryos of the Third Week.
In the previous article (" N. Y. Med. Journal," Aug. 22,
1885, p. 197) it was shown that in the earliest known stages
of man the ovum is normally, probably, a vesicle of some
3 to 4 mm. diameter, bearing short, simple chorionic villi,
and having at one side in its interior a small heap of rounded
cells, which mark out the so-called germinal area. In other
placental mammals a corresponding stage occurs, and is fol-
lowed in them by a stage characterized by the appearance
of the so-called primitive streak and groove — temporary
structures, which show, however, the axial line of the future
embryo. This stage is again followed by a third, in which
the medullary folds and groove arise ; the former are two
longitudinal ridges on the outer surface of the germinal
area. These ridges begin in front of the primitive streak,
and run back alongside it ; in front the two ridges unite ;
the depressed space included between them is the medullary
groove. The fourth stage (His's fourth and fifth) is charac-
terized by the appearance of the first myotomes (proto-
vertebra) and the commencement of the closure of the
medullary groove to form the medullary canal. The closure
is effected by the groove growing deeper and narrower until
the upper edges of the lateral ridges come in contact and
finally coalesce.
We distinguish these four stages :
First. Stage of the germinative area.
Second. Stage of the primitive streak.
Third. Stage of the medullary groove.
Fourth. Stage of the myotomes.
The known specimens of the first stage have been
already considered. No human ova of the second stage have
yet been described. His suggests that Schwabe's embryo
(V) and Bruch's (10) may have been in the third stage.
Schwabe's embryo I consider much older, and have referred
to it, accordingly, below. In regard to Bruch's ovum I will
not venture an opinion, as his description is not a very
available one. Of the fourth stage we have four specimens
recorded, but, unfortunately, not one of them has been
described adequately, according to the present standards.
We proceed to their consideration.
3. THE YOUNGEST KNOWN HUMAN EMBRYOS (FOURTH STAGE).
As just stated, the number of these is four. Their
probable age is about fourteen days. The least advanced
is His's embryo E (1, Heft i, p. 145), of which only His's
sketches are available, the attempt to microtome the speci-
men not having been fortunate. The ovum was presuma-
bly normal; it measured 8-5 by 5*5 mm., and was entirely
covered by short branching villi. For the convenience of
the reader I have constructed from the author's sketches
and descriptions the accompanying diagram. His states that
Oct. 10, 1885.] MINOT: THE EARLY STAGES OF HUMAN DEVELOPMENT.
the chorionic vesicle bore at one point a thick stalk, Al,
which ran to the posterior end of the embryo ; the length
Fig. 1.— Diagram op His's Embryo E. Age 14 ? days ; length about 23 mm.
The embryo is not represented in quite its natural attitude ; the proportion
of the parts is not accurate ; the villi of the chorion and the vessels on the
yolk are purely diagrammatic as to their number and shape. Emb, embryo ;
Al, supposed stalk of the allantois.
of the embryo from the anterior extremity to the base of
the stalk was 2*6 mm. The head end of the embryo was
somewhat thickened, and apparently showed the medullary
groove still open ; that is, the tube of the central nervous
system was not yet closed. The small, round yolk-sac had
a broad connection with the ventral surface of the embryo.
The amnion sprang from the allantois and passed over the
head of the embryo. The disposition of the caudal ex-
tremity was not made out. There were no limbs, gill-clefts,
nor organs of any kind discernible — not even a protuberance
between the head and yolk-sac, such as marks the position
of the heart in older embryos.
Allen Thomson (2) published an excellent article on
young human ova in 1839. He gives a very good critical
review of what previous authors had written, and describes
himself three embryos, which have become classical, for the
figures and descriptions given of them by Thomson have
been copied again and again. They are especially known
by the reproductions in Kolliker's embryologies and in
Quain's Anatomy. Two of these embryos (numbered i and
ii by Thomson) belong in the group we are now consider-
ing. I can not, however, admit at present that either of
them is certainly fully normal, though, perhaps, they are
only slightly malformed.
In number i (see Kolliker's "Grundriss," 1884, Fig. 112,
and " Entwickelungsgeschichte," 1879, Fig. 225) the yolk-
sac was abnormally dilated and the characteristics of the
embryo were not ascertained. His (1, Heft ii, 35, 36) has
shown that probably the embryo proper was not observed,
and that what Thomson called the embryo was really only
the amnion, springing from the allantois-stalk and passing
over the embryo. Kolliker questions the accuracy of this
interpretation, but upon what ground is not evident, for, so
far as I can see, it accords perfectly with our present knowl-
edge. The embryo in question was presumably little ad-
vanced beyond His's embryo E, Fig. 1, but had an abnor-
mally hypertrophied yolk-sac. As no sufficient descrip-
tion of the embryo exists, and as it is quite certain that the
specimen was more or less abnormal, it can not be longer
regarded as a fair representative of a young ovum.
Much more valuable is the account of Thomson's second
397
ovum, which he had better opportunities of studying. The
original description has been supplemented by His (1, Heft
ii, 34, .35), who has examined Thomson's original drawings
and called attention to an important error in the engraving
in Thomson's plate. Kolliker, however, still reproduces
the incorrect figure in the second edition of his " Grund-
riss," Fig. 114. An erroneous figure is also reproduced in
Ecker's " Icones," Taf. xxv, Fig. 3. The chorionic vesicle
measured 0-60 by 0*45 of an inch, and was covered with
branching villi. The contained embryo was very small ; ac-
cording to Kolliker, only 2*5 mm. The embryo rested upon
the round yolk-sac of 2 '2 mm. The embryo consisted of
two thick longitudinal ridges (Fig. 2, A), which curved
round in front so as to become continuous with one another,
and were broken off posteriorly — an important fact noted by
His (cf. sup.). These ridges are presumably the medullary
Fig. 2.— Thomson's Second Ovum. A, embryo from above ; B, embryo from
behind.
folds. At the hind end of the embryo was a tear, making
a hole into the hollow yolk-sac. As His suggests, this
is probably where the allantois was inserted and broken off.
No amnion was observed, and the nature of the connection
of the embryo with the chorion was not ascertained. What
we learn from this embryo is something more definite than
is afforded by His's observations as to the size and disposi-
tion of the medullary ridges and the hollowness of the
yolk-sac. The evident hypertrophy of the yolk-sac en-
forces caution as to accepting the embryo as normal ; but
it is not rare to find in abortions a small typical embryo
with an enormously dilated chorion, so that it is not im-
possible that the embryo in the present case was quite
normal.
The fourth embryo of this group, His's SR (1, Heft i,
140-144), measured 2-2 mm. in length, and was probably
fourteen days old. The chorion was 9 by 8 mm. in diame-
ter. It shows considerable advance of development beyond
the three embryos above considered. The neck of the yolk-
sac is already somewhat contracted, or, in other words, the
connection between the embryo and the yolk-sac is no
longer so broad and long as it was. The head is considera-
bly enlarged ; between it and the anterior wall of the yolk-
sac is a large thickening corresponding to the heart. From
the underside of the caudal extremity runs off the stalk of the
allantois, which is still short and thick ; the amnion lies quite
close to the embryo ; the medullary ridges are still separated
by an open, though deep, and relatively narrow groove ;
myotomes (protovcrtebrse, auct*) are present, but their
* It must be remembered that the term protovertebrse is an entire
misnomer, and is inherited from the time when the primitive muscular
segments (myotomes) were mistaken for the comnieneements of the
vertebrae. Kolliker has maintained that they participate in the forma-
398
MINOT: THE EARLY STAGES OF HUMAN DEVELOPMENT. [N. Y. Med. Jouk.
number was not ascertained. When the embryo is viewed
in profile, the middle of the back shows a marked concavity,
which lias been noticed in other older embryos, and is,
probably, an artificial distortion. We shall have to return
to this matter. Small openings were visible on the inner
surface of the chorion. These I take to be the openings
to the still hollow villi, such as have been seen in both
younger and older ova. His attempted to obtain sections
of his specimen, but, when cut, the sections fell into frag-
ments.
Summary. — The development of the chorion and am-
nion in man is exceedingly precocious. The youngest em-
bryos known are in the neighborhood of 2-2 mm. in length.
(Thomson gives the length of his embryo i as 2'5 mm., but
the criticisms made above render it plain that this measure
probably refers to the length of the amnion plus the allan-
tois-stalk ; the embryo not seen by Thomson was presuma-
bly shorter.) The embryo has a broad attachment to the
yolk-sac, which in diameter nearly equals the length of
the embryo and is already furnished with blood-vessels.
The most conspicuous character of the embryo is the pres-
ence of two very thick dorsal ridges — medullary folds —
running the whole length of the embryo and inclosing the
medullary groove — central nervous system to be — between
them ; the cephalic extremity is somewhat thickened ; from
the ventral side of the caudal extremity springs the short
and thick allantois-stalk, the opposite end of which is in-
serted into the chorion. The amnion completely incloses
the embryo and is attached on the one hand to the allantois-
stalk, on the other to the embryo nearly parallel to the
junction of the embryo and the yolk-sac.
The next change involves not merely the growth of the
embryo, but also the thickening of its cephalic end, the
development of the great heart protuberance between the
yolk-sack and the head, the concave flexion of the back, and
the deepening of the medullary groove, which, however, stil]
remains open.
The chorion forms a relatively large vesicle, its average
diameter being about 8 mm., but the four specimens vary
from 5 -7 to 15 mm. The chorion bears villi over its whole
surface ; the villi are considerably branched. Probably the
villi are formed chiefly if not solely by epithelium, and
probably also there is a layer of connective tissue, very
likely already vascular, which lines the chorion but does
not extend into the villi.
There are many still unsolved problems as to the early
development of man. It will be observed that not a single
one of the ova hitherto noticed has been adequately investi-
gated, and that no specimens have yet been studied at all
showing the first appearance of the embryo, the origin of
the amnion, or of the allantois, or of the yolk-sac ; and,
finally, that of all the earliest stages our knowledge is ex-
tremely imperfect. It is therefore much to be hoped that
all who obtain available specimens will carefully preserve
them and intrust them to a competent investigator. From
the above considerations it is also evident that the summary
just given can be only tentative.
tion of the vertebra?, but even this view is entirely erroneous. The
term protovertebiae ought to be immediately banished for ever.
4. ORIGIN OF THE ALLANTOIS.
It will be remembered that in birds the allantois very
early becomes a free sac. It has been supposed by some
writers that the allantois of man grew out in the same man-
ner. Haeckel even went so far as to prophesy that when a
human embryo of the right stage should be obtained it
would be found to have a free allantois. Very shortly after
W. Krause (3) published a description of an embryo with
free allantois which he stated was human. Both Haeckel
and Krause were, however, mistaken, the former through
hasty and unfounded speculation, the latter from an error
as to the identity of his embryo. Krause's embryo was, I
think it may be said certainly, not human, probably not even
mammalian, but avian. Krause still maintains that it is
human ; it agrees in all essential particulars with a chick,
and disagrees utterly in shape with all known normal human
embryos. The discussion as to this specimen was long and
animated, but has now little interest except historically. In
the literature cited at the close of this article I have given
the reference to Krause's original article, and under the same
head (3) references to the discussion.
To explain the origin of the human allantois we have
only the following hypothesis of His, no direct observations
being available. In an earlier stage the embryo is supposed
to form over the germinal area upon the surface of the blas-
todermic or chorionic vesicle ; below it lies the yolk-sac
(see the accompanying diagram, Fig. 3, A, V) ; on all sides
Fig. 3. — Diagrams to show the Formation of the Human Amnion. A,
first stage ; B, second stage ; Am, amnion ; At, allantois ; Ch, chorion, the
villi of which are drawn smaller and more numerous than they are in na-
ture ; P, yolk-sac.
the tissue of the embryo passes over into the chorion, Ch ;
posteriorly the connection between the embryo and the
chorion is marked by a thickened band (probably of meso-
dermic cells originally part of the hind end of the primitive
streak) ; this thickened band persists and becomes the allan-
Oct. 10, 1885.]
MINOT: THE EARLY STAGES OF HUMAN DEVELOPMENT.
399
tois-stalk ; around the head of the embryo a fold is formed,
Am, the beginning of the amuion ; this fold grows back
farther and farther over the embryo as indicated by the
dotted line, Am', Fig. 3, A ; finally the tip of the fold
reaches the allantois-stalk, and, uniting with it, produces the
arrangement shown in Fig. 3, B, which is the same as Fig.
1, and is known from actual observation.
This account may be accepted as hypothetically correct.
I think it probable that the allantois first arises as a heap
or mound of cells, pre-anal and ventral in position, and hav-
ing a very small, short, nearly cylindrical cavity, which in
its turn arises as a diverticulum of the hind gut, and is,
therefore, lined with entoderm. This is the manner in
which the allantois starts apparently in all amniota in regard
to which observations on this point are available ; general
analogy leads us to expect that in man also the course of
tained, and there is never a free allantois save that it forms
at first for a short time a small more or less independent
protuberance.
A word as to the homologies of the allantois. Its proxi-
mal portion becomes, as is well known, the bladder of the
adult. It has been maintained by Balfour (" Comparative
Embryology," ii, p. 256), and it is the generally accepted
opinion, that the allantois is evolved as a modification of
the bladder. This view I believe to be erroneous; the
bladder of amphibia is a dorsal diverticulum of the intes-
tine, and can not be homologized with the amniote bladder,
which is a ventral diverticulum. The amphibia (and ga-
noids) have, too, a long-known embryonic structure, which
is a ventral diverticulum of the intestine and extends into
a considerable accumulation of mesodermic cells below the
blastopore (anus). This diverticulum I hold to be a rudi-
Fig. 4.— Ovum supposed to be prom Fifteen to Eighteen Days Old ; after Coste. The chorion has been opened and spread out to show the embryo and
its annexa. Al, allantois-sttlk ; Am, amnion surrounding the embryo.
development is similar. But since in man there is no caudal
amnion, nothing intervenes, so far as we know at present,
between the allantoic outgrowth of the embryo and the
chorion ; hence it seems the primitive connection is main-
mentary allantois, and, in fact, it precisely agrees, even as
to details, with the commencing allantois of amniote verte-
brates. This obliges us to consider the allantois as primi-
tive, and the bladder of the Amniota as a secondary deriva.
400
If WOT': THE EARLY STAGES OF HUMAN DEVELOPMENT. [N. Y. Mkd. Joint.,
tive of the allantois, precisely the reverse of Balfour's
theory. The homology drawn also renders it probable that'
the allantois arose very early, since we find traces of it in
the ganoid fishes. In this case it will no longer be strictly
accurate to regard Allantoidea and Amniota as synonymous
terms, as they are now used. On the contrary, it appears
that the allantois is a much older structure than the amnion,
and the bladder of the 'amniota is a modified allantois and
not homologous with the bladder of the Ichthyopsida.
5. EMBRYOS OF THE FIFTH STAGE.
Formation of the Gill-Clefts. — We now reach a series of
embryos, several of which have been well studied and beau-
tifully drawn. Two of them belong to the stage now under
consideration — namely, the youngest embryo described by
Coste in his great work, and His's embryo L. Both descrip-
tions are satisfactory, save that in regard to the dimensions
of Coste's embryo no certainty can be had. Coste's private
collection is, I believe, now in the College of France, but upon
search this particular specimen could not be found, so that
His's inquiries to ascertain its actual length were resultless.
Kolliker states that it was 4-4 mm. long, but his authority for
the statement is not given ; the measure was probably taken
from Coste's figure marked "grandeur naturelle." Since
embryos of this length are far more developed than Coste's,
it is probable that Coste's data as to the magnification of
his figures are inaccurate. If we assume the embryo to
have been really about 2*5 mm. long, it will then agree, ex-
cept as to the great length of the rump, very closely with
what we know otherwise of such young embryos.
I give the accompanying figures, which are careful copies
from the original plates published by Coste (4, Espece hu-
maine, PI. II), whose illustrations, made by his assistant,
Gerbe, have never been surpassed for beauty and life-like
accuracy. The embryo in question was inclosed in a villous
chorion, Fig. 4, and was provided with a large vitelline
sac, Vi, having a very broad connection with the embryo
and covered with a network of vessels, in which was a fluid
not yet red. A thick allantois-stalk, Al, can be seen run-
ning from the under side of the embryo's tail to the chorion;
from the anterior side of the stalk springs the amnion, Am,
completely inclosing the embryo. It is important to notice
that in this, as in still older embryos, the disposition of the
amnion is essentially the same as in the earliest stages
(v. sup.) ; the line of attachment of the amnion is down the
sides of the allantois and around the embryo about on a
line with the top of the yolk. As regards the embryo, it
is drawn slightly canted on to its left side; its back is con-
cave ; the head end is thickest, and shows three gill-arches,
hence there were probably two branchial clefts ; bebind and
below the gill-clefts can be seen the heart, already a bent
tube, shining through ; behind the arches again, but on the
dorsal side, the light-looking oesophagus is distinguishable ;
in the figure a wedge-shaped shadow intervenes between the
straight oesophagus and the bent heait; the heart causes a
conspicuous bulging of the body between the head and the
yolk-sac ; the caudal extremity is thick and rounded, and
curves upward.
Fig. 5 is a ventral view of the same embryo after most
of the yolk-sac has been cut off; its walls, Spl (splanchno-
pleure), are seen to pass over without any break into those
of the intestinal cavity. In the central line the chorda
Fig. 5.— Embryo supposed to be from Fifteen to Eighteen Days Old ;
after Coste. Ventral view ; the vitelline sac has been removed. Am,
amnion ! Ill, heart ; Spl, splanchnopleure, extending beyond the embryo
to form the yolk-sac ; S, chorda dorsalis with a row of myotomes on each
side ; Al, stalk of the allantois.
dorsalis, s, can be perceived through the translucent dorsal
wall of the intestinal cavity ; it is flanked on each side by
the row of square muscular segments (myotomes). We see
the large allantois, Al, behind, and in front the tubular
heart, Ht, with a decided flexure to the right of the em-
bryo ; the anterior end of the heart makes an opposite
bend, separating off a limb, which becomes the bulbus
aorta.
The chorion consisted of two membranes, one of which
passes continuously over the inner surface of the chorion,
while the other outer membrane alone forms the hollow
villi, Figs. 4 and 6 ; hence, in looking at the inside of the
-Mes.
<
Fig. 6. — Fragment of the Chorion of Fig. 4, highly magnified. Ec, epi-
thelial layer; Mex, connective-tissue layer; Vi, chorionic villi, formed
wholly of epithelium.
chorion, we see numerous round openings which do not
penetrate the inner membrane. Fortunately we learn from
Oct. 10, 1885.]
FOWLER: HYDRONAPHTHOL ; A NEW ANTISEPTIC.
401
Kolliker (" Entwickelungsgeschichte," 1879, p. 309), who
had an opportunity in 1861 to examine this chorion, that
the outer membrane was epithelial, with cells of the same
character as in the epithelium of older vascularized villi,*
and that the inner layer consisted of developing connective
tissue and carried fine blood-vessels. It thus appears that
Coste was the first to observe the role of the epithelium in
the growth of the villi, which 'was discussed in the previous
article.
{To be concluded.)
HYDRONAPHTHOL;
A NEW ANTISEPTIC.
By GEORGE R. FOWLER, M. D.,
SURGEON TO ST. MART'S GENERAL HOSPITAL, BROOKLYN.
{Continued from page 375.)
In order to satisfy myself as to the solubility of this
compound, observations having in view the determining of
this point with some degree of accuracy gave the follow-
ing: In hot water it will dissolve in the proportion of one
part in a hundred, and a residue of an oily or tarry sub-
stance occurs, which latter, upon boiling the solution, melts
and floats about on the surface. If the water be only
warmed to a temperature of 70° C, the residue is found at
the bottom of the flask. Upon filtering the solution and
allowing the filtrate to cool to 17° C, the excess of hydro-
naphthol crystallizes, leaving a solution of the strength of
1 to 800. By reducing the temperature still lower, or by
vigorous shaking, a further quantity is thrown down, leav-
ing a solution of the strength of 1 to 1,100, which latter
remains permanent.
It dissolves in cold water to the extent of one part of
the hydronaphthol to two thousand parts of water. To
effect this, however, it is necessary that it should remain in
contact with the water, or be occasionally agitated. The
clear filtrate from this solution has the characteristic taste
of hydronaphthol and possesses antiseptic properties.
To test for the presence of the hydronaphthol in solu-
tion, add a few drops of the solution of the subacetate of
lead, when a white precipitate will be thrown down. Or
the addition of chloride of sodium to the solution will cause
its separation in a fine white precipitate, giving the liquid a
milky appearance.
The tarry material which floats about in a melted con-
dition upon the surface of the hot solution is probably
alpha-naphthol, an impurity which will, no doubt, be gotten
rid of in the course of a further experience in the manu-
facture of the compound. It does not interfere with the
antiseptic qualities of the solution, nor does it do other
harm, as far as is at present ascertained.
In order to ascertain to what extent hydronaphthol could
be relied upon to prevent the occurrence of putrefactive
changes in animal tissues and fluids, the following prelimi-
nary observations were made :
* " Hierbei zeigte sich, dass die Zotten und die sie tragende Haut
ganz und gar aus epithelartigen Zellen, von derselben Beschaffenheit,
wie die des Epithela der spiiteren gefasshaltigen Chorionzotten be-
stehen."— Kolliker, I. c.
First, three solutions were prepared for use, the first
containing 1 gramme of hydronaphthal in 1,000 grammes
of warm water, the second containing 1 gramme in 1,500
grammes of water, and in the third 1 gramme in 2,000
grammes of water. In all of these solutions fresh animal
tissue (beef) was placed, and, to afford a control test, a piece
of the same beef was placed in a similar flask containing pure
water, and all of the tests were exposed to a temperature of
about 21° C. in an ordinary room, and as nearly as possible
to the same general conditions, with the following results :
At the end of twenty-four hours the flask containing the
beef and water only showed signs of decomposition, and in
the course of another twenty -four hours had broken down
completely. The other three flasks, after one hundred and
twenty hours' exposure, were found to have undergone no
change, and were in a perfect state of preservation.
As beef solution is the medium generally employed for
the purpose of testing the power of antiseptic substances,
the following experiments were made : The beef solution
was first filtered while hot, and then solutions of hydro-
naphthol made in this vehicle. In the first 1 gramme of
hydronaphthol was dissolved in 1,000 grammes of the warm
beef solution, in the second 1 gramme was dissolved in
1,500 grammes, and in the third 1 gramme was dissolved
in 2,000 grammes. A control test was likewise prepared
in the same manner, but without the addition of the anti-
septic. These were all placed under the same conditions,
as to temperature, etc., as in the preceding experiments,
with the following results : At the end of twenty-four hours
the control test began to exhibit some turbidity, and before
forty-eight hours had elapsed indubitable signs of advanced
decomposition were present. All three of the solutions
containing the hydronaphthol, however, at the end of one
hundred and twenty hours, were found in their normal con-
dition.
The addition of 1 part of the antiseptic to 1,000 parts
of fresh urine has maintained the latter in a perfect state of
preservation for four .months, and probably will continue to
do so indefinitely. Solutions of glue and gelatin, so prone
to decomposition, have been preserved by the addition of
the antiseptic in the proportion of one twentieth of one
per cent, throughout the warm summer months, and in the
same proportions the formation of mold or mildew was
prevented in such moist organic compounds as mucilage,
starch and glue pastes, dyewood and other extracts.
The results of these observations encouraged me to seek
still further light upon the subject of the antiseptic proper-
ties of hydronaphthol, and to ascertain to what extent its
preservative powers could be carried, and to likewise deter-
mine if these depended upon a germicidal action on the one
hand, or upon a simple inhibition of the growth of bacteria
on the other. With this end in view, I sought the assist-
ance of Dr. G. M. Sternberg, the well-known authority
upon disinfectants and antiseptics. That gentleman was
about to sail for Europe to be gone for a period of six
months or longer, but proffered me the services of his first
assistant, Dr. Abbott, at the laboratory of the Johns Hopkins
University, in Baltimore. These I gladly accepted at once,
and during the past three weeks experiments Inning the
402
FOWLER: HYDROS A PfTTITOL ; A N~EW A NTI8EPTIC.
[N. Y. Med. Jour.,
object of determining the following points have been car-
ried on : First, its germicide value on broken-down beef-
stock containing pathogenic spore-bearing organisms, mi-
crococci, and putrefactive bacteria ; second, its value in
destroying pure cultures of anthrax and pure cultures of
pathogenic micrococci ; and, third, its value as an antisep-
tic (the prevention of development without killing the or-
ganisms).
In the first place, the insolubility of the hydronaphthol
was found to be an insuperable bar to any germicidal action
in its normal solution (Ol per cent.). A mixture was there-
fore made of 1 gramme to 100 c. c. of water (1-0 per cent.),
this being about ten times above saturation. This mixture
was tried on putrefied beef-tea containing putrefactive and
pathogenic organisms and spores, on anthrax pure, on sub-
tilis pure, and on pure cultures of pathogenic micrococci.
To these it was added in equal proportions — that is to say,
ten cubic centimetres of the substance to be disinfected
and the same quantity of the one-per-cent. mixture of hy-
dronaphthol were added together. This gave five tenths of
one per cent. (0-5 per cent.) of the hydronaphthol present,
being five times above saturation. A drop of the fluid
containing the organism was, after two hours' exposure, in-
troduced into the flasks containing sterilized solution of
beef peptones, the culture medium generally used in disin-
fectant experiments, and, after the standard length of time
of exposure in the incubator (two hours), in all the tubes
the respective organisms were found to be present. This
showed that when the substance wTas present in a mixture
five times above saturation it was not germicidal to these
organisms and spores. These experiments seemed to at once
settle the question as to its germicidal powers.
In order to test its power as an antiseptic, the following
experiments were made : Eleven flasks were prepared, each
containing 100 c. c. of solution of beef peptone, to which
hydronaphthol was added in the following proportions : 1
to 100, 1 to 500, 1 to 800, 1 to 1,000, 1 to 2,000, 1 to
4,000, 1 to 6,000, 1 to 8,000, 1 to 10,000, 1 to 16,000, and
a flask in which none of the antiseptic was placed. These
were inoculated with two drops of decomposed beef-tea,
and placed in the incubator. The flask put up for
comparison, and which contained none of the hydronaph-
thol, broke down completely in twenty-four hours. The
other flasks, from the strongest up to the l-to-6,000 solu-
tion, and including the latter, after one hundred and twenty
hours' exposure in the incubator, resisted the development
of decomposition, the first failure taking place in the 1-to-
8,000 flask.
The following is a summary of these experiments:
1. As a germicide it failed to disinfect decomposed
beef-tea containing pathogenic organisms and spores when
present in 0-5 per cent. 2. It failed to prove germicidal to
pure anthrax, pure subtilis, and pure micrococci, in the same
strength. 3. As an antiseptic it proved to be active in ar-
resting the development of the bacteria in the proportion
of 1 to 6,000, and failed only when the l-to-8,000 solution
was reached.
That the value of an antiseptic agent does not neces-
sarily depend upon its germicidal powers is a well-estab-
lished fact;* it is further well known that some agents of
well known germicidal power are inapplicable as antiseptics, j
To the class of agents which prevent or arrest putrefactive
changes, without necessarily destroying the organism upon
which these changes depend, but rather whose potency h? |
attributable to their influence in holding in check their
development, Lister has given the name of "inhibitory"
agents, or antiseptics having an "inhibitory action." f
The importance of this distinction can not be overrated,
for it has been the custom in the past to use the words
"germicidal," "disinfectant," and "antiseptic" in a loose
manner, and, in some instances, as synonymous terms. The
impropriety of this is at once obvious, and it is now grow-
ing to be the custom to speak of such substances as are
both germicidal and antiseptic as simply germicides or dis-
infectants ; while those which are antiseptic without pos-
sessing the power of killing organisms endowed with a pe-
culiarly tenacious hold upon life, such as those of anthrax
and pathogenic micrococci, are called simply antiseptics.
For the present, this distinction will perhaps be the best
attainable, with our present want of knowledge of the life-
history of these lower organisms. For instance, Sternberg J
asserts, and there can be no reason for questioning the
opinion of this authority, that " the vital resistance of bac-
terial organisms to chemical reagents differs, within certain
limits, for different species." Hence, unless some standard
of vitality, so to speak, were established, different observers
would use the distinctive terms " disinfectant," " germicid-
al," and " antiseptic " with different meanings, and no end
of confusion would result. It is perhaps best, therefore,
that the term germicide or disinfectant should be limited to
such agents as will destroy reproductive spores, inasmuch
as these possess powers of resistance far in excess of bac-
terial organisms in which active development takes place
by the process known as " multiplication by fission."
Taking, therefore, the reproductive spores, such as those
of the anthrax bacilli, as the standard for the test of strength
of a germicide, very few of the agents supposed to be
active germicides are found to be efficient in solutions
which would be safe to employ in practical surgical work.
The most notable exception to this will be found in corro-
sive sublimate, and, as elsewhere shown, this agent is not
a stable antiseptic. But, when the next most popular anti-
septic, carbolic acid, is brought forward for comparison, its
impracticability for general use as a germicide will be at once
apparent when the statement is made, upon the authority
of Koch,* that, for the certain destruction of the spores of
the anthrax bacilli, an aqueous solution of carbolic acid of
the strength of 1 to 10 is necessary. This, for purposes of
application in wound treatment, is manifestly impracticable.
The well recognized rule || — that " The effect which a sub-
stance introduced into a wound as an antiseptic may have on
the exposed surfaces of the wound must be taken into consid-
* Koch, " Mittheilungen des Kaiserlichen Gesundheitsamtes," Band
i, Berlin, 1881.
f " British Medical Journal," October 25, 1884, p. 804.
\ "American Journal of the Medical Sciences," April, 1883, p. 343.
* " Mittheilungen des Kaiserlichen Gesundheitsamtes," etc., p. 236.
I Pilcher, "The Treatment of Wounds," New York, 1883.
Oct. 10, 1885.]
FOWLER: HYDRONAPHTHOL ; A NEW ANTISEPTIC.
403
era t ion in choosing one for use, as well as its effect upon the
germ supposed to be present " — has a direct bearing upon the
question at issue.
Of all the substances which are at present known to
have an inhibitory action upon bacteria, and hence are in
the true sense antiseptic, with the sole exception of corro-
sive sublimate, hydronaphthol is the most powerful. By
reference to the following table, adapted from Sternberg
by Pilcher,* showing the comparative value of the agents
named in their power to arrest the development of the micro-
coccus from pus, this claim will find undeniable corrobora-
tion. According to Sternberg, the other organisms of this
class, bacteria termo, etc., are inhibited by about the same
strength of antiseptic as that necessary for pus micrococci,
and therefore this table may be cited for purposes of com-
parison :
TABLE OF MINIMUM STRENGTHS OF ANTISEPTIC AGENTS REQUIRED TO
INHIBIT GERM-DEVELOPMENT.
Efficient in the
Antiseptic agent. proportion of one part to
Mercuric bichloride 35,000
Iodine 4,000
Sulphuric acid 1,800
Carbolic acid 500
Salicylic acid and sodium biborate, equal parts 200
Boric acid 200
Ferric sulphate 200
Sodium biborate 100
Alcohol 10
According to the experiments above detailed, hydro-
naphthol is efficient in the proportion of between 1 to
6,000 and 1 to 8,000, and in the table just quoted would
occupy the position next to mercuric bichloride. In other
words, as an antiseptic it is about one fifth as powerful as the
mercuric bichloride; from one and a half times to double the
strength of iodine ; four times as strong as sulphuric acid ;
at least twelve times as efficient as carbolic acid ; thirty times
as potent as salicylic acid, when sodium biborate is added
to the latter (for the purpose of increasing its solubility) in
the proportion of equal parts of each ; thirty times as power-
ful as both boric acid and ferric sulphate ; sixty times as
strong as sodium biborate, and six hundred times as strong
as alcohol.
In making solutions for surgical use, it is my custom to
add a sufficient quantity to a teacupful of hot water to super-
saturate the same ; this produces a milky mixture. Suffi-
cient water at the ordinary temperature is then added to
this to make it a clear solution. Or powders of seven
grains and a half each, or compressed tablets containing the
same quantity, may be at once dissolved in a pint of warm
water. The latter would constitute a convenient and port-
able form for use in private practice. In my hospital serv-
ice, the irrigator jars are kept about two thirds full of the
solution, having an excess of the hydronaphthol at the bot-
tom. By adding a quantity of hot water to the solution
just before it is required for use, a super-saturated solution
is at once obtained. After the solution has been for a few
days in contact with the excess at the bottom of the jar, the
latter precaution may be found to be unnecessary. The
* Pilcher, " The Treatment of Wounds," New York, 1883.
saturated solution may be used for washing the site of opera-
tion, the surgeon's hands and those of his assistants after
scrubbing with mercuric bichloride solution in case of sus-
pected infection ; for saturating towels for the purpose of
isolating the field of operation ; as a bath for the instru-
ments ; for washing the sponges and for irrigating the
wound.
In the preparation of silk and catgut it would be safest,
especially in the case of the latter, to first immerse the gut,
wound upon glass or hard-rubber spools, in Kummei's solu-
tion of mercuric bichloride (one half of one per cent.) for
twelve hours, and then preserve it permanently in a one-
per-cent. alcoholic solution of hydronaphthol. Silk may be
boiled in the first-named watery solution of sublimate
and kept, for protection, in the hydronaphthol alcoholic
solution as used for the gut. This method of sterilizing
catgut and silk I prefer to all others as being the safest. It
has been asserted by its originator that it will afford perfect
protection against infection, even though the gut be made
from an animal dead of anthrax. I am particular in mak-
ing this statement here in order to qualify a remark con-
cerning the sterilizing of gut by means of hydronaphthol,
made in the first portion of this article. I also prefer to
trust to the well-known germicidal power of a freshly pre-
pared solution of sublimate in the first preparation of
sponges, as well as their subsequent purification after an
operation, where they are used more than once. But they
can be kept with advantage in the hydronaphthol solution,
after sterilizing, until needed for use. So also with horse-
hair for sutures and drains, and rubber drainage-tubes ;
after sterilizing in mercuric-bichloride solution, the hydro-
naphthol solution, from its reliability and absence of tend-
ency to decompose, will be found far preferable for purposes
of permanent preservation. I am led to emphasize this
statement by the fact that it has happened to me recently
to find sponges, placed in a l-to-1,000 solution of corrosive
sublimate — which latter at first was certainly germicidal —
after a few weeks developing a most sickening, putrid odor,
and to afford other evidences of having undergone putre-
factive changes, even showing a well-marked growth of
mold upon the surface of the solution in the screw-capped
fruit-jar in which they had been placed. This can only be
attributed to the want of stability of the bichloride solution
and the decomposition of the sublimate in the solution into
the submuriate, a very feeble as well as insoluble disinfect-
ant. This can not happen in the hydronaphthol solution,
as the latter remains without change for an indefinite time
(so far as can at present be ascertained), as well as preserves,
against putrefactive changes, organic substances of whatever
nature, particularly if these have been previously subjected
to the germicidal action or sterilization of such a potent
agent as a freshly prepared solution of corrosive sublimate.
When a spray is used, a solution of the strength of one
per cent, in alcohol may be used in the reservoir of the
atomizer. This, when mingled with the steam from the
boiler of the instrument, can be diffused in the atmosphere
with advantage where it is considered that a spray adds to
the thoroughness of the antiseptic measures.
The softness of the crystals of hydronaphthol and the
404
SEXTON: NEGLECTED EAR DISEASE IN INFANTS.
[N. T. Mbd. Join.,
facility with which tbey cling to the meshes of gauze, cot-
ton, jute, etc., render the substance peculiarly well adapted
for incorporation in these materials for the purpose of ren-
dering them permanently antiseptic for surgical purposes.
Messrs. Seabury & Johnson, of New York, have made, at
my request, gauze and cotton dressing containing twenty
per cent, of the antiseptic, and I can testify to their effi-
ciency and reliability.
Cushion dressings of wood-flour, paper-wool, and saw-
dust are used in my hospital service almost exclusively;
these can be readily saturated with a warm solution of hydro-
naphthol in water of the strength of 1 to 500, in which
also mercuric bichloride is dissolved in the same proportion.
The bichloride in this solution will be sufficiently germicidal
to destroy any possible source of infection, and the hydro-
naphthol will furnish the permanent antiseptic. No chlo-
ride of sodium need be added to the solution for tbe pur-
pose of preventing the decomposition of the corrosive sub-
limate, as the latter will be sufficiently stable to perform its
office of sterilizing the dressing, and, when this is accom-
plished, it is of no further use, and, in fact, will soon be
converted into calomel.
After saturating the wood-flour, sawdust, or paper-wool
with the above-named solution, the two former should be
spread out to dry in a place free from dust. If an alcoholic
or benzole solution be used, drying will go on rapidly and
but slight risk be encountered of the materials becoming
again infected by any possible floating germs in the air. In
the case of paper-wool, the drying may be facilitated by
running the material through a clothes-wringer. Should the
sawdust or wood-flour dry in lumps, as it is apt to do when
the watery solution is used for impregnating, these may be
readily broken up by rubbing them through a common
flour-sieve. When an alcoholic or benzole solution is used
for the purpose, no such after-treatment of the wood-flour
or sawdust is necessary.*
It is sometimes thought to be good practice to dust
along the line of incision some absorbent powder possess-
ing antiseptic properties. For this purpose I have found
carbonate of magnesia, having triturated with it the hydro-
naphthol in the proportion of 2 to 100, a very desirable and
efficient substitute for iodoform.
(To be continued.)
TWO CASES or
NEGLECTED EAR DISEASE IN INFANTS,
RESULTING IN DEATH. f
By SAMUEL SEXTON, M. D.,
AURAL SURGEON TO THE NEW YORK EYE AND EAR INFIRMARY.
Grave and even fatal ear disease in early life is of much
more frequent occurrence, probably, than is generally sus-
pected. Inflammation of the middle-ear tract may thus
arise from head catarrh or other cause and rapidly extend
* The addition of a small proportion of glycerin to the solutions
used for impregnating the wood-flour and sawdust will prevent the ten-
dency of the latter to fly about when handled.
f Read by title at the annual meeting of the American Otological
Society, July 14, 1885.
itself to the dura mater without the warning usually given
by the occurrence of a discharge from the external auditory
canal. Or the discharge, once established, may suddenly
cease because of the closure of the outlet through the drum-
head, the secretions escaping via the Eustachian tube, which
is proportionately very large in infancy. The causes of
special danger will be alluded to farther on.
In the two following cases, occurring in very young in-
fants, however, early evidence was not wanting, even to the
inexperienced, of serious aural trouble, and death was due
to their neglect and ill-directed treatment.
Cask I. — Otitis Media Purulenta ; Polypus; Facial Pa-
ralysis; Pachymeningitis ; Death. — N. N., of Jewish parent-
age, aged six months, was brought to my clinic at the New York
Eye and Ear Infirmary, in March, 1884, with the following his-
tory : When three months old he was exposed to a draught
coming through an open window while traveling in a railway
carriage. A few days afterward a circum-auricular swelling
was observed to take place, which was, by order of the attending
physician, poulticed with chamomile flowers, hops, and Indian
meal for three weeks continuously. The purulent matter which
had been collecting was then liberated with a lancet. After
discharging a week the opening was allowed to close, but sub-
sequently it was again opened and dressed with a tent and some
antiseptic salve. The ear and wound were syringed three times
a day with an aqueous solution of one drachm of carbolic acid
to the pint— the solution passing freely through from the wound
into the canal. This treatment had been persisted in until the
date of coming to the infirmary. The child's mother thinks two
considerable - sized sequestra were removed by the syringing
about four weeks ago. The discharge, it is alleged, varies
from time to time, and is now absent. The child nurses well
and sleeps fairly well.
Examination. — The lumen of the external auditory canal is
obstructed with pus, the removal of which brings to view a
large polypoid growth which fills the canal.
There is partial right facial paralysis.
March 13th. — Discharge from the ear and sinus more free
to-day, but the child is restless. The polypus was removed by
Sexton's snare. It was found to be of much greater size than
had been expected, filling the tympanum and canal almost to
the meatus externus. It was about half an inch in length and
somewhat nodulated. There was free haemorrhage after avul-
sion, which was, however, soon arrested by instillations of hot
water.
The treatment consisted in gentle cleansing with warm water
as required, afterward dressing the parts with calendula and
boric acid. Internally the calcium sulphide in small doses was
given several times daily.
15th. — There is diminution in the quantity of the discharge,
which is less purulent. General appearance is better, and the
restlessness which existed before the operation is less.
I did not again see the patient ; his mother, however, came
several months after to the infirmary to report his death. She
said that the next day after his last visit he became more rest-
less, had a cough, and raised mucus. Vomiting occurred after
nursing or taking food or medicine, and continued until death,
which took place on April 5th. The child ceased to nurse three
days before death, and for two days no discharge from either
the meatus or sinus was observed. He had convulsions for two
weeks, at the beginning of which "his face became straight
again " (double facial paralysis), and at the end there was strabis-
mus. These symptoms, taken together with the previous his-
tory, point to pachymeningitis. It seems probable that the
Oct. 10, 1885.]
SEXTON: NEGLECTED EAR DISEASE IN INFANTS.
405
rapid recurrence of the polypoid growth, blocking up the out-
lets and preventing drainage, may have hastened the result.
The physician who attended the patient at home certified that
he died of " pneumonia, convulsions, and dentition."
The apparent absence of suffering during the early part of
the progress of the disease is noteworthy. There was no au-
topsy.
The polypus removed was examined by Dr. Frank Ferguson,
and found to be a myxo-fibroma. The following are the notes
of the examination :
The tumor is covered throughout by mucous membrane,
excepting at the points of attachment. Covering this mucous
membrane, near the points of attachment, are laminated cylin-
drical cells. In the same region the mucous membrane is ar-
ranged in large papillae, which can be seen with the naked
eye. Elsewhere the surface of the tumor is smooth and cov-
ered by flat epithelium. Beneath the mucous membrane are
large numbers of round cells. The center of the tumor is
composed of fibrillated and granular material, numerous small
round cells, and mucous corpuscles. The vascular supply is
abundant.
Case II. — Otitis Media Purulenta, complicated with Lym-
phadenomaof theNeclc, resulting in Caries of the Atrium, Attic,
Antrum, Tympanic and Auditory Plates; Facial Paralysis,
Purulent Meningitis ; Death; Autopsy. — Albert S., a mulatto,
aged seven months. The patient was brought to the New York
Eye and Ear Infirmary in June, 1885, with the following his-
tory :
Three months previous to this date a small swelling ap-
peared in front of the left tragus, coincident with a purulent
discharge from the left ear. The swelling extended downward,
rapidly enlarging, forming a large, irregular mass, occupying
the whole of the left side of the neck. One month ago the
otorrhcea ceased almost entirely, and at the same time the child
was taken to a city dispensary and placed under local and gen-
eral medicinal treatment for the glandular tumor. During this
period of treatment the tumor fluctuated in size, a discharge
appeared in the right ear, and the child became very restless
and irritable, sleeping poorly, attacks of vomiting alternating
with diarrhoea ; and left facial paralysis was noticed for the first
time.
Examination, June 1st. — The left meatus was occluded by
granulation tissue, which was removed, giving vent to a large
quantity of very offensive purulent matter. The canal was di-
lated, the posterior and inferior walls presenting an ulcerated
granular surface, the drum-head was entirely destroyed, and the
tympanum presented a large cavity caused by the necrotic de-
struction of portions of the annulus tympanicus and temporal
plate, the inner wall of the attic and atrium, the antrum and
auditory plate. In a word, the bony walls of the large patho-
logical cavity thus exposed to view were denuded in every
direction ; the ossicles were absent, with the exception of the
stapes, which could be seen lying loosely upon the upper and
posterior part of the inner wall. The right meatus was filled
with granulation tissue which sprouted from the walls of the
canal, the drum-head was destroyed, and denuded bone could
be detected with the probe in any portion of the tympanum.
On the left side of the neck there were a number of lymphade-
nomata aggregated together, forming a large, irregular tumor,
limited above by the inferior attachment of the auricle, and be-
low by the level of the thyroid gland. No fluctuation could be
detected in any portion of the mass. There was complete left
facial paralysis.
Treatment. — Small and frequently repeated doses of the
tincture of aconite and calcium sulphide were given, the canals
being cleansed and powdered boric acid insufflated once daily.
During the next eight days the patient's condition improved
somewhat.
June 8th. — Restless and irritable, with some febrile move-
ment; temperature 102°; vomiting frequently. Discharge from
ears free.
10th. — The patient became drowsy and stupid, and had gen-
eral convulsions. Coma supervened, and he died June 12th.
Autopsy. — The dura mater is healthy, with the exception of
that portion covering the superior surface of the left petrous
bone, which is much thickened from the deposit of neoplastic
tissue, and at points presents isolated centers of ossification.
There is purulent meningitis of the convexity, the deposit of
lymph being more particularly noticeable along the margins of
the longitudinal fissure and on the under surface of the anterior
and posterior cerebral lobes. The cortical substance is quite
soft, and there is considerable accumulation of greenish offen-
sive matter in the subarachnoidean cavity. No connection could
be traced between the ear] and glandular enlargement on the
neck.
The accompanying wood-cut, somewhat enlarged, shows the
outer surface of the left temporal bone after the specimen had
been prepared. The absence of the osseous portion of the ex-
ternal auditory canal at this age brings the inner wall of the
tympanum, which is very large, well into view ; 1 is the prom-
ontory of the inner wall, and just above it is the foramen rotun-
dum from which the stapes has escaped. The inner wall of the
attic was gone, exposing the horizontal semicircular canal. The
walls of the antrum and the adjacent cellules were eroded away
and the entire auditory plate was honey-combed. The auditory
plate, 5, which was scarcely united to the squamous and mas-
toid portions, was undergoing sequestration, entirely denuded,
and a sinus, 6, afforded communication between the antrum and
an abscess beneath the periosteum.
The annulus tympanicus composing the anterior wall of the
external auditory canal is shown at 2 ; it is roughened all around,
as is the tympanic plate itself. The rudimentary mastoid pro-
cess is seen at 3; the under surface of the petrous bone at 4.
Tho squamous portion is shown at 7, 7 ; the parietal bone at
8, 8.
On the inner surface of the specimen, not shown in the cut,
is seen an extensive opening along the line of the petro-squa mo-
sal suture through which, probably, the inflammatory process
extended to the dura.
406
LINCOLN: MELA NO-SARCOMA OF THE NOSE.
[N. Y. Med. Jock.,
It is probable that in this case the inflammation extended it-
self from the tympanum along underneath the auditory plate
into the antrum, while a periostitis externa manifested itself on
the outer surface.
Remarks. — In reviewing Case I, it seems remarkable
that so little nervous irritability existed during the progress
of the case, although the ear was deeply attacked. With
the exception of the last two or three weeks, the child suf-
fered but little, and, so far as pain was concerned, it may not
have seemed important to the ordinary observer.
To the retention of secretions, the formation of which
was actively promoted by the three weeks' persistent poul-
ticing, and perhaps also to the vigorous syringing, was
doubtless largely due the gravity of this case.
Although the treatment of a case in this advanced stage
is somewhat expectant, yet it is generally best to administer
frequently small doses of pulsatilla or aconite during the
active progress of the disease in order to allay nervous irri-
tability.
Acute aural inflammation in children often gives rise to
symptoms well calculated to puzzle the general practitioner;
and hence its presence is liable to be unsuspected ; ttftis, in
Case I, the alleged cause of death as reported to the Bureau
of Vital Statistics did not include the aural trouble.
When the proportionately large area of the middle-ear
tract in children is considered, one need not experience any
surprise at the frequency of its invasion by disease. The tym-
panum, antrum, and Eustachian tube thus comprise a very
much exposed region which occupies a dangerous proximity
to the dura mater — being separated by an extremely thin
plate of bone, often imperfectly closed by osseous tissue
especially along the line of the petro-squamosal suture. Free
vascular communication is afforded through this thin parti-
tion between the middle ear and the dura, and, in any in-
flammatory process in either, the other is extremely liable to
be affected.
The important knowledge to be obtained by observing
the phenomena manifesting themselves in the ear in children
is not available always without an expert examination ; and
this becomes a much more difficult matter when exterior
manifestations are wanting, since deafness and distressing
autophonia, etc., can not always be explained by children,
and never by very young infants, and pain in such cases
may be relegated to another region. Although recovery
may take place when the aural symptoms are not recog-
nized, yet deafness may remain.
Too much stress can not be placed on the advisability
of avoiding a meddlesome and heroic plan of treatment,
often practiced that "something mav be done."
In these neglected cases it is well to remember that the
danger does not lie in an invasion of the mastoid cellules,
since the mastoid process exists in a rudimentary state only
before the age of puberty, but in an extension of the in-
flammatory process to the antrum, caries of the bone being
consecutive thereto. An independent but coincident attack
of periostitis externa may indeed take place. Where the
latter occurs alone, recovery is usually much more rapid,
since, under proper treatment, reabsorption of pus takes
place, or it is evacuated by the knife.
Sometimes large sequestra, consisting of portions of the
auditory or tympanic plate, or of portions of bone contain-
ing the cochlea or semicircular canals, are removed after
sequestration in these cases, especially in broken down or
scrofulous subjects. It is surprising to witness the rapidity
with which recovery often takes place after the detachment
of very large pieces of temporal bone. Officious surgical
meddling in these cases can but be most injurious, since it
is not wise to attempt to separate sequestrating from healthy
bone until Nature has completed her share of the process.
We have our hands full, generally, in the effort to maintain
proper drainage. I have of late found strands of antiseptic
catgut, as prepared by Mr. Am Ende, of Hoboken, intro-
duced into either the sinus which usually exists behind the
auricle, or into the external auditory canal, a very effective
means of drainage. Beyond this, and dressings consisting
of boric acid and calendula locally, I have found it a good
plan to let the ear alone and treat the patient.
I am indebted to my assistants, Dr. William A. Bartlett
and Dr. Robert Barclay, for the admirable care which these
patients received while under observation. To them I am
also indebted for the notes of the post-mortem of Case II,
which was under Dr. Bartlett's charge.
A CASE OF
MELANO-SAKCOMA OF THE NOSE
CURED BY GALVANO- CAUTERIZATION*
By R. P. LINCOLN, M. D.,
NEW YORK.
In November, 1884, Mrs. L. presented herself for con-
sultation, and supplied the following history :
In August, 1882, she first noticed an obstruction to free
respiration in the right nostril, and about the same time was
annoyed by a continual muco-purulent, blood-stained discharge
from the same nostril. There was also matter of a similar
appearance which was expectorated, and which evidently came
from the posterior nares.
Her general health at this time was good, and there was
little or no pain.
It was not till the following winter that this nostril became
completely occluded, when operative interference was decided
upon.
Dr. D. Hayes Agnew, of Philadelphia, removed the growth
April 2, 1883. After a microscopic examination, he announced
its character as " cancerous." After a period of about two
months a repetition of the former symptoms manifested them-
selves; these continued to increase until November following,
when Dr. Agnew repeated his first operation.
A few months of uncertainty succeeded the second opera-
tion, but frequently recurring haamorrhages and renewed diffi-
culty in breathing gave assurance of a recurrence of the tumor
until February, 1884, when the growth seemed to increase very
rapidly. At this time the patient placed herself under the care
of a physiciau in Rome, in this State, a man of much repute
among the people, who used, in the words of the patient,
"plasters and pastes " for about two months, when he confessed
his inability to remove the trouble. Notwithstanding this treat-
ment, the tumor continued to grow.
* Read before the American Laryngological Association, June 25,
1885.
Oct. 10, 1885.J
BOOK NOTICES.
407
On examining the patient, I found the right side of the nose,
extending well up to the inner can thus of the eye of the corre-
sponding side, enlarged, the fullness amounting to about four
times the size of the left side of the nose.
The lower half of its ala was wanting, the remaining border
being puckered, somewhat contracted, and of a purple color,
which gradually faded until the integument was of normal ap-
pearance half way up this side of the nose. There protruded
from this nostril, about half an inch, a dark-colored, fleshy mass
completely filling it ; this was attached to the outer margin of
the nostril as well as to its floor. A plum-colored discharge
was constantly flowing from the nostril, and the lightest touch
of the mass with a probe was followed by dark grumous blood.
A further careful exploration showed the tumor to grow from
the lower and middle turbinated bones, and from the floor of
the nostril for a distance of two inches and a half. The septum
was free.
A rhinoscopic examination disclosed the tumor protruding
into the post-nasal cavity and occupying about half of it. I
proposed a removal of the growth with the galvano-cautery ecra-
seur and a subsequent cauterization of points of attachments as
offering the best chance of relief.
November 18, 1884, the patient submitted to operation, Dr.
Delavan and Dr. Goodwillie being present and kindly giving
their assistance. The patient being etherized, I passed the
platinum-wire loop of the galvano-cautery ecraseur about the
tumor at its attachments and thus separated it.
Immediately afterward the seat of the growth was thor-
oughly cauterized. The loss of blood was inconsiderable. For
a week after the operation a solution of bicarbonate of sodium
and carbolic acid was injected into the nostril many times a
day; after this an ointment containing two grains of iodoform
to an ounce of vaseline was applied to the healing surface
three times a day.
Two weeks after the operation the patient was permitted to
go to her home in Pennsylvania, with no diseased point dis-
coverable and with perfectly free respiration through the nostril.
May 27, 1885. — The patient returned at intervals of one or
two months, the last time on this date, for observation. No
further treatment has been necessary, as the parts are perfectly
healthy. The integument, formerly discolored, has assumed a
normal appearance. The remaining deformity is hardly notice-
able, far less than the most hopeful would have expected.
I present herewith a specimen of the tumor mounted
for microscopic examination, together with a report of the
microscopic appearance, both of which were made by my
friend Dr. Frank Ferguson.
His report I quote :
" The cut surface is dark, with small areas of dark gray and
flesh-colored tissue. Under the microscope the portion of the
tumor which is flesh-colored is composed of round and ovoid
cells of medium size. The cells are close to each other and dis-
tinctly nucleated. The darker portions of the tumor are haem-
orrhages. The areas of dark gray are composed of large flat
cells deeply pigmented. The cells are supported by a stroma of
fibrillated and granular material. There are numerous large
vessels seen throughout the tumor, some of them with thick
walls ; also a few gland-ducts, probably the remains of glands
belonging to the tissue in which the growth originated.
" There are numerous haemorrhages throughout the entire
tumor, in some places large, in other places punctate. Prog-
nosis grave."
Note. — Information received from the patient October 1st showed
that there were no indications of a return of the disease.
ooh flotixes.
A Treatise on Nervous Diseases; their Symptoms and Treat-
ment. A Text-book for Students and Practitioners. By
Samuel G. Webber, M. D., Clinical Instructor in Nervous
Diseases, Harvard Medical School, etc. New York : D. Ap-
pleton & Co., 1885. Pp. ix-415.
There has long existed a demand for a concise and definite
statement of the elements of neuro-pathology and therapeutics.
The student about to begin the study of neurological medicine
is confronted by a literature of ominous extent, in the mazes of
which he is ill-prepared to tread without the aid of personal
tutelage. In Germany this condition of affairs has been recog-
nized, as a number of little text-books bear witness; but in this
country and England the want has been but inadequately met.
We have very complete treatises, it is true, as well as mono-
graphs of no mean value; and yet the fact remains that, until
the advent of the little book before us, the profession has
been without a concise statement of the elements of neuro
pathology.
In the face of this obvious deficiency, Dr. Webber's little"
book comes to us as a welcome addition to our library. To those
who are unable to attend the special clinics of a large city, and
who are, nevertheless, desirous of acquiring a knowledge of the
principles of neuro-diagnosis, it will undoubtedly render good
service. As an introduction to a course of special reading it is
also well adapted. Thus, in the beginning of the book will be
found a brief statement of the practical points of cerebral anato-
my and physiology; and this theoretical portion of the volume
is immediately followed by a section of considerable extent
treating of the analysis of symptoms. We then come to the
chapters on special cerebral diseases. These are handled in a
terse manner, the author giving what he considers are the essen-
tials of diagnosis and therapeutics.
The chapters on the diseases of the spinal cord are written
in the same practical spirit, and, like those on cerebral patholo-
gy, are preceded by a concise statement of the essential ana-
tomical and physiological questions involved.
In the latter half of the volume the diseases of the periph-
eral and sympathetic nerves receive attention.
None of the subjects brought forward are treated of exhaust-
ively ; nor can the author be justly taken to task for super-
ficiality, since his very object is conciseness. Enough that he
has fulfilled his task in a manner which leaves nothing to be
desired.
We have no hesitation in recommending this admirable little
book to students and practitioners alike.
BOOKS AND PAMPHLETS RECEIVED.
Medical Communications of the Massachusetts Medical So-
ciety, Vol. xiii, No. 5, 1885. Boston : Printed by David Clapp
& Son, 35 Bedford Street, 1885. Pp. 321-501. And Proceed-
ings of the Councillors. Pp. 85-113.
Proceedings of the Connecticut Medical Society, 1885.
Ninety-fourth Annual Convention, held at Hartford, May 27th
and 28th. New Series, Vol. iii, No. 2. Published by the So-
ciety, S. B. St. John, M. D., Secretary. Hartford, Conn. : Press
of Case, Lockwood, and Brainard Company, 1885. Pp. 3-239.
Vaginal Hysterectomy for Cancer. By A. Reeves Jackson,
A. M., M. D., Professor of Gynaecology in the College of Physi-
cians and Surgeons of Chicago, etc. Read in the Section of
Obstetrics and Gynaecology at the Thirty-sixth Annual Meet-
ing of the American Medical Association. [Reprinted from the
"Journal of the American Medical Association."]
408
LEADING ARTICLES.
[N. Y. Mki.>. Jocp.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, OCTOBER 10, 1885.
THE AMERICAN MEDICAL ASSOCIATION'S NEW
COMMITTEE'S SUB-COMMITTEE.
It seems that what was said to be sauce for the goose is
not considered to be sauce for the gander. In April the Lace-
daemonian cry went up that the committee that was originally
intrusted with the organization of the Ninth International
Medical Congress was merely authorized to carry out the will
of the American Medical Association, and that its work was in
every respect subject to the revision of the association. This
cry carried the day, and the New Orleans meeting proceeded
to revise the committee's arrangements with a vengeance — with
what results, the country is but too well aware. The associa-
tion's pet committee, however — those gentlemen who were
chosen to supersede the legitimate body — soon found that there
was no further occasion for the responsibility alleged by the
New Orleans meeting; or, rather, it is a sub-committee that
has made that discovery.
Our readers will remember that the reconstructed commit-
tee held a meeting in New York on the 3d and 4th of Septem-
ber, at which a sub-committee, styled an executive committee,
was constituted, and that the further prosecution of the work
of patching up the organization of the Congress was given into
the hands of this sub-committee. The "Journal of the Ameri-
can Medical Association " now informs the world that the
executive committee held a meeting in New York on the 24th
of September, at which, "more than a quorum" being present,
it perfected its organization ^by^electing Dr. Henry H. Smith,
of Philadelphia, chairman, and Dr. Frederic S. Dennis, of New
York, associate secretary- general, after which, " to prevent all
further misunderstanding, both at home and abroad," it unani-
mously adopted the following remarkable resolution: "Re-
solved, That this executive committee enters upon the manage-
ment of the affairs of the Ninth International Medical Congress
with the understanding that, in accordance with rule No. 10,
its powers are not restricted except by the rules and regula-
tions adopted September 3, 1885, by the committee of arrange-
ments appointed by the American Medical Association in April,
1885 ; and that the actions of this executive committee are
final, not being subject to revision, amendment, or alteration
by either the committee of arrangements or the American
Medical Association."
Indeed! Is this "understanding" supported on an opinion
by Speaker Randall ? And if, in this instance, not only is the
so-called "committee of arrangements " not subject to over-
sight by the organization that appointed it, but even a sub-com-
mittee is answerable neither to it nor to its creator — nor, in
fact, to any power on eaith — we would like to know how Mr.
Randall likes the tricks and the manners of the coterie whom
he so kindly accommodated with his opinion in the early part
of the summer.
For our part, we are perfectly well satisfied. We have all
along maintained that the original committee ceased to be a
committee of the American Medical Association the moment
its invitation was accepted at Copenhagen, and that at the same
moment it became, by adoption, a committee of the Congress,
responsible to it, arid to it alone. As a legitimate corollary of
that position, we have held that the original committee was
under no sort of obligation to report to the New Orleans meet-
ing. We are able to say now that such indeed was the convic-
tion of the truly representative men in the old committee, but
that they were seduced into a course of conduct that was urged
upon them as being in the interest of conciliation, whereas no-
real conciliation was ever intended by the seducers. The sub-
committee is now quite of our way of thinking — mutatis mu-
tandis ; and we wish it joy.
MINOR PARAGRAPHS.
THE PROPOSED NEW NATIONAL MEDICAL ASSOCIATION.
We would call attention to a letter, signed " Subscriber,"
which we publish in another column, and beg to assure our
readers that the writer of the letter is a gentleman who has
paid a good deal of attention to matters connected with medi-
cal organizations, and has on more than one occasion given evi-
dence of a willingness to sacrifice his own favorite projects
when convinced that the welfare of the profession would be
better served by the substitution of other measures. It will be
seen that the plan he now brings forward gives abundant scope
for the settlement of details in a leisurely way, which is cer-
tainly wise and conservative. The point on which most solici-
tude ought to be felt seems to us to be the manner of constituting
men members of the association. That is the rock on which
the American Medical Association has struck. At first, its
members were the representative men of the profession, but, as
fresh delegations were eligible year after year, a less and less
representative set was chosen, until finally the organization be-
came utterly unworthy of its early history, and ceased to enjoy
the confidence of the profession.
TULIT ALTER HONORES.
In a review of the first volume of Pepper's "System of
Medicine," the "Lancet,". of London, says:
" Variola, Vaccinia, and Varicella have been intrusted to the pen of
Dr. James Nevins Hyde." ..." The writer's article on Vaccinia strikes
us as one of the most candid and lucid that have been written upon this
much-discussed topic. He is not so blind as to refuse to grant that
vaccination sometimes fails to protect, but he rightfully declaims against
the tendency to irrational generalization which sees in this fact the con-
demnation of the practice. His statement appears to -us as particularly
fair — viz., that ' vaccination almost invariably protects against small-
pox for the time being; generally for a long term of years; sometimes
for a lifetime. Often the protection is absolute ; as a rule it is very
nearly so ; in rare instances it is trifling.' Again, in dealing with the
complications of vaccination, he takes up a very candid position with
regard to the risks of erysipelas, of vaccinal syphilis, etc. He declares
in favor of bovine over humanized virus after a full discussion of the
arguments on cither side, saying that ' in barely one particular — that of
promptness of action — can humanized virus justly be credited with any
superiority, while in every other essential respect it is inferior, so far
Oct. 10, 1885.|
MINOR PA RAO RAPES.
409'
as any difference is to be observed.' At the same time he does not
admit that there is any proof of the deterioration of the Jennerian
vaccine."
Praise and blame deserved but withheld are about even in
most men's lives. We trust, therefore, that we shall not be
looked upon as actuated wholly by considerations of meum and
tuum if we state that, of the three articles mentioned by the
" LaDcet," the one on Vaccinia was written, not by our excel,
lent friend Dr. Hyde, but by the editor of this journal.
THE STATE OF NEW YORK AND THE CANADIAN
SMALL-POX EPIDEMIC.
Last winter the accidental Governor of the State of New
York, who is now a candidate for re-election, distinguished
himself by, inter alia, pandering to the rage for a penny-wise
and pound-foolish economy by refusing to sign a bill appropri-
ating the inconsiderable sum of fifteen thousand dollars for the
use of the State Board of Health in case of emergency. At the
time, we pointed out the criminal foolishness of the Governor's
course. The emergency is now upon us, for there is every rea-
son to apprehend that the Canadian outbreak of small-pox will
cross the frontier unless the most energetic precautions are
taken. Unless the people of the State are willing to submit to
the inconvenience of an extraordinary session of the Legislature,
we know not how they can be defended, save at the far greater
expense of sucking Government pap — an expense to their honor
that will not tally well with their past record. Already the ap-
prehension felt in Buffalo, together with the rumors of outbreaks
at Rouse's Point and other localities, can not be viewed other-
wise than as disquieting.
A DANGER TO THE ARMY MUSEUM AND LIBRARY.
Some anxiety has been expressed — although not publicly, so
far as we know — lest the operation of the general order limit-
ing the time for which officers of the army could be stationed
in Washington should involve the removal of Dr. Billings from
the further prosecution of the grand work upon which he has
spent so many years. That work is still far from being fin-
ished, ami we can not see how the public interests could fail to
suffer by Dr. Billings's transfer to another field of duty. It is
not to be wondered at, therefore, that the possibility of sucb an
occurrence should be looked upon with alarm. There can be
no doubt, however, that it can be avoided without violation of
the spirit of the order, and we are convinced that there can be
little less doubt that the Government will take good care that
it is avoided. We look, then, to see Dr. Billings continued in
the sphere which he has so adorned, and we are sure that such
a course is earnestly desired by the profession.
NEWS ITEMS, ETC.
The New York Quarantine Service.— The service in the
Lo wer Bay was discontinued on the 1st of October, a month
earlier than usual, owing mainly, it is said, to the comparative
freedom of Havana and other tropical ports from yellow fever.
The Health of the State of New York.— The State Board
of Health's "Monthly Bulletin" for the month of August shows
a reported mortality of 7,284, which is considerably lower than
that for July. But this, it is explained, is partly accounted for
by the failure to receive reports from Buffalo, Long Island City,
and a number of large villages. The percentage of infant mor-
tality was 46-73. Zymotic diseases caused 337 31 deaths in
every 1,000, diarrhoea] diseases 230, consumption 128-87, and
acute respiratory diseases 57-52. The board has issued a most I
useful circular on the prevention of small-pox, setting forth the
laws on the subject, and giving information as to the general
management of an outbreak.
Infectious Diseases in New York— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending October 6, 1885 :
Week ending Sept. 29.
Week ending Oct. 6,
DISEASES.
Cases.
Deaths.
Cases.
Deaths.
39
16
46
8
15
2
19
2
Cerebro-spinal meningitis. . . .
2
2
1
1
4
0
3
1
39
19 .
28
8
3
8
6
0
Precautions against Small-pox. — The Board of Health of
Fall River, Mass., has accepted an offer from the New Hamp-
shire State Board of Health, which proposes to issue tickets of
inspection to all persons from the infected Canadian districts
who pass through the State en route for Fall River. The tickets
will indicate whether the holders have been vaccinated ; and, if
a passenger from Canada can not produce a ticket, the inference
will be that he has thrown it away, and be will accordingly be
quarantined, unless he can account for its absence. The medi-
cal inspector at Fall River will vaccinate all who need it, and
the most rigorous measures will be enforced to prevent the in-
troduction of the disease into the city.
The Contagious Pleuro-pneumonia of Cattle is reported
to have been wholly suppressed in Illinois, and the Governor of
that State will therefore shortly take steps toward securing a
discontinuance of the quarantine measures adopted in other
States.
The Management of the Montreal Small-pox Epidemic
having been offered to Dr. Edwin M. Snow, of Providence,
Rhode Island, that gentleman is reported to have accepted the
offer conditionally.
The Health of Foreign Cities.— We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office since
the date of the last bulletin, September 30th : Montreal, Canada.
— For the week ending September 29th : 297 deaths from small-
pox occurred in Montreal during the week. From September
26tb to 29th, inclusive, there were 48 deaths from small-pox in
the towns adjoining the city. The official reports give the fol-
lowing record of deaths from the disease in Montreal to Sep-
tember 23d: In April, 6; May, 10; June, 13; July, 46; Au-
gust, 239 ; September 1st to 22d, inclusive, 524. Total to that
date, 838. The disease has spread with great rapidity during
September. During the first five days the deaths were 77; for
the week ending 12th, 128; six days and a half ending 18th,
184; September 19th to 22d, inclusive, four days, 135. Three
Rivers, Canada. — For the week ending September 26th : 5 cases
and 1 death from small-pox ; disease spreading through the vil-
lages in the consular district. Toronto, Canada. — September
30th: No new cases reported. Havana, Cuba. — For the two
weeks euding September 24th : 47 cases and 20 deaths from
yellow fever. Cardenas, Cuba. — September 19th : Free from
epidemic diseases. Matanzas, Cuba. — September 23d: Inter-
mittent fever prevalent. San Domingo. — September 14th : Free
from epidemic diseases. London, England. — For the week end-
ing September 14th : 9 deaths from small-pox, including 6 of
London residents who died outside of the registration district.
Paris, France. — For the week ending September 12th : 7 death*
from small-pox; 34 cases treated in hospital. Bordeaux, France.
410
MINOR PARAGRAPHS.
[N. V. Mao. Jolb.,
— For the week ending September 19th: 4 deaths from small-
pox. Barcelona, Spain. — September 1st to 10th : 623 cases and
302 deaths from cholera; disease assuming a milder form.
Cadiz, Spain. — September 12th: Total mortality 155, average
40; excess attributed to cholera. Santander, Spain. — Septem-
ber 19th: Cholera decreasing. Gibraltar, Spain. — By telegram
September 30th : Authorities to-day issue clean bills of health.
Valencia, Spain. — September 5th : Cholera decreasing; no new
cases in the village during the week. Genoa, Italy. — Septem-
ber 13th: 1 death from small-pox. Venice, Italy. — For the
week ending August 29th : 6 deaths from small-pox. Palermo,
Italy. — September 18tb: Consul reports cholera increasing, and
states that about forty thousand of the inhabitants have fled
from the city. Trieste, Austria. — For the week ending Septem-
ber 12th: 13 1 cases and 4 deaths from small-pox. Antwerp,
Belgium. — For the week ending September 12th: 4 cases of
small-pox. St. Petersburg, Russia. — For the week ending Sep-
tember 12th: 1 death from small-pox. Warsaw, Russia. — For
the week ending September 12th: 2 deaths from small-pox.
Calcutta, India. — For the week ending August 22d : 14 deaths
from cholera. Colombo, Ceylon. — For the week ending August
22d : 44 cases and 18 dearhs from cholera Guaymas, Mexico. —
September 23d : Consul reports yellow fever increasing and be-
coming more virulent ; 138 cases and 36 deaths from the disease
since September 1st; it has also appeared at Hermosillo. Ma-
zatlan, Mexico. — September 15th : Consul reports yellow fever
present in sporadic cases ; statistics of deaths can not be ob-
tained ; authorities continue to issue clean bills of health. Dur-
ing August 28th, 29th, and 31st, and September 1st and 2d (the
report for August 30th has not yet been received), there were
in Spain 17,147 cases of cholera and 5,466 deaths. The total
number of cases and deaths from March 4th to September 2d
is 232,105 cases and 86,692 deaths.
Personal Items.— The " Medical Times," of Philadelphia,
announces that Dr. George M. Sternberg, of the army, has been
elected an honorary member of the Royal Academy of Medicine,
of Rome; also that the following changes in the residences of
Philadelphia physicians have been made: Dr. Roberts Bartho-
low to 1525 and 1527 Locust Street, Dr. Theophilus Parvin to
1718 Walnut Street, Dr. Charles K. Mills to 1909 Chestnut
Street, and Dr. B. F. Baer to 2010 Chestnut Street, and that
Dr. J. M. Holland has taken an office at No. 1914 Rittenhouse
Square. Professor McCall Anderson sailed from New York by
the Servia, Dr. Charles E. Sajous, of Philadelphia, by the West-
ernland, and Dr. W. L. Ranney, of New York, by the Adriatic,
last wreek. The list of arrivals from abroad during the same
week included the names of Dr. Major, of Montreal, Dr. G. H.
Lyman, of Boston, and Dr. G. G. Wheelock, of New York.
Our readers will be glad to learn that Dr. Fordyce Barker has
so far recovered his health as to be able to make a visit to
Boston.
An Attempt to " Boycott " a Physician is reported from
Elizabeth, New Jersey. According to the newspaper accounts,
a Roman Catholic priest denounced the physician from the pul-
pit as an apostate, and warned his parishioners against employ-
ing him, threatening them with a refusal to perform the offices
of the Church in their behalf in case they disobeyed the warn-
ing.
The Johns Hopkins University School of Medicine.— The
Baltimore correspondent of the Philadelphia "Medical Times'*
states that it is rumored that Professor Matthew Hay, of Edin-
burgh, has been elected professor of pharmacology.
A Museum of the Vegetable Materia Medica.— We learn
that Messrs. Parke, Davis, & Co., of Detroit and New York, are
prepared to furnish students with a very complete set of speci-
mens of the crude vegetable drugs, arranged within a moderate
compass, with each specimen numbered to correspond with a
printed list. The value of such a collection to students of mate-
ria medica can not well be over-estimated, and the price asked
($10) is so low as to bring it within the reach of all.
An Honor to a Physician.— The "Union medicale" states
that, on the recommendation of the director of the Bourboule
Spring, the municipal authorities of the place have decided to
name one of the principal streets for the late Dr. Noel Gueneau
de Mussy, who took a prominent part in bringing the virtues of
the Bourboule waters into notice.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from September 27 to October 3, 1885 :
McPaulin, T. A., Colonel and Surgeon. Directed to transfer
his duties and the public funds for which he is accountable,
as Assistant Medical Purveyor, to Captain Henry Johnson,
Medical Storekeeper, who will, in addition to his present
duties, temporarily perform the duties of Assistant Medical
Purveyor, New York city. S. O. 223, A. G. O., September
29, 1885.
Caldwell, D. G., Major and Surgeon. Ordered from Fort
Laramie, Wyoming, to Fort D. A. Russell, Wyoming. S. O.
97, Department of the Platte, September 28, 1885.
Baetholf, J. H, Captain and Assistant Surgeon. Ordered
from Fort Ringgold, Texas, to Fort Mcintosh, Texas, for
duty as Post Surgeon. S. O. 125, Department of Texas,
September 28, 1885.
Beechemin, Louis, Captain and Assistant Surgeon. Ordered
from Fort D. A. Russell, Wyoming, to Fort Laramie, Wyom-
ing. S. O. 97, Department of the Platte, September 28, 1885.
Macauley, C. N. B., First Lieutenant and Assistant Surgeon.
Relieved from duty at Fort A. Lincoln, Dakota Territory,
and ordered for duty at Camp Poplar River, Montana Terri-
tory. S. 0. 105, Department of Dakota, September 21, 1885.
Knudlee, William L., First Lieutenant and Assistant Surgeon.
When relieved from duty at Camp Poplar River, Montana
Territory, by Assistant Surgeon Macauley, to report to com-
manding officer, Fort Snelling, Minnesota, for duty. S. O.
105, Department of Dakota, September 21, 1885.
Wales, P. G., First Lieutenant and Assistant Surgeon. Re-
lieved from temporary duty at Boise Barracks, and ordered
for duty at Fort Cceur d'Alene, Idaho. S. O. 160, Depart-
ment of Colorado, September 21, 1885.
Ewing, C. B., First Lieutenant and Assistant Surgeon. Re-
lieved from duty at Fort Stanton, New Mexico, and ordered
for duty at Fort Leavenworth, Kansas. S. O. 147, Depart-
ment of the Missouri, September 25, 1885.
Naval Intelligence. — Official List of Changes in the Medi-
cal Corps of the United States Navy for the weeTc ending October
3, 1885.
Jones, William H., Surgeon. Ordered to Navy- Yard, League
Island, Pa., October 15th, as the relief of Medical Inspector
M. Bradley.
Beadley, Michael, Medical Inspector. Detached from Navy-
Yard, League Island, Pa., October 15th, and placed on wait-
ing orders.
Owens, Thomas, Assistant Surgeon. Ordered to Naval Station,
New London, Conn., as the relief of Surgeon William A.
Cor win.
Coewin, William A., Surgeon. Detached from Naval Station,
New London, Conn., and ordered to the U. S. Steamer
Adams, October 31st.
Oct. 10, 18N5.J
LETTERS TO TEE EDITOR.
411
Magruder, A. F., Surgeon. Ordered to the U. S. Steamer
Yantic, without delay, as the relief of Surgeon H. L. Law.
Law, H. L., Surgeon. Detached from the U. S. Steamer Yan-
tic, and wait orders.
Simon, W. J., Surgeon. Detached from the Naval Academy,
October 1st, and wait orders.
Drennan, M. 0., Surgeon. Detached from the Naval Academy,
October 1st, and wait orders.
Cabell, Arthur G., Passed Assistant Surgeon. Assigned to
the U. S. Steamer Adams, October 31st.
Marine-Hospital Service. — Official List of Changes of
Stations and Duties of Medical Officers of the United States
Marine-Hospital Service, for the week ended October 3, 1885,
BAiLnAOHE, P. EL, Surgeon. Detailed as chairman of board
for the physical examination of officers of the Revenue- Ma-
rine Service. September 28, 1885.
Vansant, John, Surgeon. Order to New Orleans, La., re-
voked. To proceed to St. Louis, Mo. October 2, 1885.
Ptjrvianoe, George, Surgeon. To proceed to Louisville, Ky.,
as inspector. October 1, 1885.
Gassaway, J. M., Surgeon. Detailed as chairman of board for
the physical examination of officers of the Revenue-Marine
Service. October 3, 1885.
Godfrey, John, Surgeon. Order of September 16th amended.
To proceed without delay to Louisville, Ky. September 28,
1885.
GoLDSBOROUGn, C. B., Passed Assistant Surgeon. Order of Sep-
tember 16th amended. "When relieved, to proceed to Chi-
cago, 111. October 1, 1885.
Irwin, Fairfax, Passed Assistant Surgeon. Detailed as re-
corder of board for the physical examination of officers of
the Revenue-Marine Service. September 28, 1885. To
examine physically and instruct crews of the Life-Saving
Service, Third District, in the method of restoring the ap-
parently drowned. October 3, 1885.
Banks, C. E., Passed Assistant Surgeon. Detailed as recorder
of board for the physical examination of officers of the
Revenue-Marine Service. October 3, 1885.
Society Meetings for the Coming Week :
Monday, October 12th: New York Ophthalmological Society
(private) ; New York Medico-Historical Society (private) ;
New York Academy of Sciences (section in Chemistry and
Technology) ; Boston Society for Medical Improvement;
Gynaecological Society of Boston ; Burlington, Vt., Medical
and Surgical Club; Norwalk, Conn., Medical Society "(pri-
vate).
Tuesday, October 13th : New York Medical Union (private) ;
New York Surgical Society ; Medical Societies of the Coun-
ties of Rensselaer, Chenango (tri-annual), Greene (semi-
annual, Cairo), Jefferson (quarterly, Watertown), Oneida
(quarterly, Utica), and Tioga (Owego), N. Y. ; Newark, N.
J., and Trenton, N. J., Medical Associations (private) ; Medi-
cal Societies of Bergen and Cumberland (semi-annual) Coun-
ties, N. J. ; Medical Society of Litchfield County, Conn, (an-
nual).
"Wednesday, October 14th: New York Pathological Society;
American Microscopical Society of the City of New York ;
New York Medico-Legal Society ; Medical Society of the
County of Cayuga, N. Y. ; Tri-States Medical Association
(Port Jervis, N. Y.); Pittsfield, Mass., Medical Association
(private) ; Franklin (quarterly, Greenfield), Hampshire
(quarterly, Northampton), Middlesex South (Cambridge),
and Plymouth (special), Mass., District Medical Societies ;
Vermont State Medical Society (annual, Montpelier); Phila-
delphia County Medical Society (conversational).
Thursday, October 15th : New York Academy of Medicine ;
New Bedford, Mass., Society for Medical Improvement (pri-
vate).
Friday, October 16th : Chicago Gynaecological Society (annual).
Saturday, October 17th : Clinical Society of the New York
Post-Graduate Medical School and Hospital.
OBITUARY NOTES.
John Light Atlee, M. D., of Lancaster, Pa., died at his
home in that city on Thursday, October 1st, in the eighty-sixth
year of his age. He was born in Lancaster, November 2, 1799,
and received his medical degree from the Medical Department
of the University of Pennsylvania in 1820. He was one of the
founders of the Medical Society of the State of Pennsylvania,
and was chosen president of the society in 1857. He was also
one of the original members of the American Medical Associa-
tion, of which he was president in 1882. In 1877 he was
elected an honorary fellow of the American Gynaecological So-
ciety. On the union of Franklin and Marshall colleges, he was
appointed to the professorship of anatomy and physiology
which he held until 1869. During the greater part of his long
career he held a number of positions of trust not connected
with medicine, and was specially interested in the public schools
of Lancaster. In connection with his brother, the late Dr. Wash-
ington L. Atlee, he was for many years widely known as a suc-
cessful ovariotomist, and he is said to have been the first sur-
geon to remove both ovaries successfully at one operation.
Many of the physicians of New York have a lively remembrance
of the genial personal attributes of Dr. Atlee as revealed to
tham at a reception given in his honor by the late Dr. Marion
Sims a few years ago, and his loss will be keenly felt by the
profession of the whole country.
Richard McSherry, M. D., of Baltimore, Md., died at his.
home in that city on "Wednesday, October 7th, at the age of
sixty-nine years. He was horn in Martinsburg, Va., received his
early education at Georgetown College, and was graduated from
the Medical Department of the University of Pennsylvania in
1841. He was immediately appointed to the medical corps of
the army, and served under General Taylor in the Seminole
War, resigning his commission in 1843. In the same year he
was appointed an assistant surgeon in the navy, in which he
served until 1851, when he resigned and settled in Baltimore.
In 1862 he was appointed to the chair of Materia Medica in the
Medical Department of the University of Maryland, and in
1865 to that of the Principles and Practice of Medicine in the
same institution. He was a member of the Medico-Chirurgical
Faculty of Maryland and of the Baltimore Academy of Medi-
cine, of which he was one of the Founders and its first presi-
dent. He was a writer of considerable repute, and the author
of several medical works.
f ctlcrs to tin Winter.
A NEW NATIONAL MEDICAL ASSOCIATION.
To the Editor of the New York Medical Journal :
Sir: As many are of the opinion that the usefulness of the
American Medical Association is at an end, and that in all
probability its future meetings will be characterized by acri-
monious debates on medical polity to the detrimont of its sci-
entific interests, the time appears ripe for the organization of a
new national medical association.
412
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
I would suggest, therefore, that it be organized in the fol-
lowing manner : Let each State medical society at its meeting
in 188G appoint two persons to represent it on a General Com-
mittee of Organization.
Early in 1887 this General Committee should he called to-
gether, the call for its meeting to be issued by the representa-
tives earliest appointed acting as temporary chairman and secre-
tary, and whose functions as chairman and secretary shall cease
on the organization of the committee.
The duty of the General Committee shall be to prepare a
plan for the permanent organization of the profession, the
plan evolved by the General Committee to be submitted to the
several State societies in 1888. If it should meet the approval
of the majority of the State societies, the General Committee
should issue a call for the general meeting of the National As-
sociation in 1889, which, when organized, terminates the labors
and functions of the General Committee.
If the foregoing propositions appear to he open to serious
objection, it is to be hoped that the objections will be formu-
lated at an early day in order that they may be modified if gen-
erally thought desirable. It is further hoped that the medical
press of the country will bring this matter before their con-
stituencies with such commentary as seems to them wise.
Respectfully yours,
Subscriber.
COCAINE IN THE TREATMENT OF OPIUM ADDICTION.
314 State Street, Brooklyn,
Saturday, September 26, 1885.
To the Editor of the New York Medical Journal:
Sir: The able and valuable paper by Dr. Bauduy on "Co-
caine in Melancholia," in jour journal of to-day, contains a
statement or two that we can not pass without comment and
dissent.
Speaking ot cocaine in the treatment of chronic alcohol- and
opium taking, he says: "It not only replaces alcohol and mor-
phine, but it generates a positive disgust for those agents. They
can be withdrawn completely and at once without the slightest
suffering or injury, and the cocaine itself may be gradually dis-
pensed with, thus eventuating in perfect recovery."
This assertion as regards morphine is so at variance with
my experience — based upon several years' exclusive professional
attention to the treatment of opium habitues, and embracing
case after case in which cocaine, in one-grain doses, subcutane-
ously, has again and again been given— that I am compelled to
express my belief that Dr. Bauduy is greatly mistaken. His
claim is entirely too sweeping, being, in effect, specific virtue
for cocaine in opium addiction, which, I assert, it — or any other
drug — does not possess. That coca — or its alkaloid — is of great
value in this disorder I willingly admit, regarding it the most
effective tonic-stimulant at command, but only as an adjunct ;
for opium addiction presents such varied reflex irritation on
abrupt or rapid withdrawal of the habitual narcotic that its
effective treatment can not be compassed by any one drug of
which we know.
Such being my belief, it seems to me quite unwarrantable to
assert that with cocaine a long-used opiate "can be withdrawn
completely and at once without the slightest suffering." I do
not believe it, and challenge proof to the contrary. It is too
much like the asserted statement of Fleisch], that, with cocaine
in the treatment of alcoholism and morphinism, inebriate asy-
lums are a thing of the past — an assertion so astounding that it
can be credited only to the vagaries of a visionary enthusiast.
Dr. B. cites one instance. A single swallow scarcely makes
a summer. Let us have canes and details.
On another point our experience differs. He mentions a
patient " for many years a hopeless victim." The morphine
was at once withdrawn ; one grain to one grain and a half of
cocaine, hypodermically, given twice daily; craving for mor-
phine immediately ceased, and all the usual sequela of with-
drawal failed to appear.
No such remarkable result has ever followed my giving of
cocaine, for invariably the effect has subsided in from two to
three hours, my latest observation on this point having been
made to-day. In this connection a paper on this topic by Dr.
J. F. Whittaker, of Cincinnati, in the " Medical News " of Au-
gust 8th, is of interest, his experience according with mine as
to the transient effect of cocaine, and his opinion of its value
being: "I am convinced that cocaine alone is not a perfect
antidote or substitute for morphine."
Regarding the danger of a coca "habit," the opinions of
these gentlemen are directly opposite, Dr. B. claiming it "a
certainty," Dr. W. asserting "the fear of a cocaine 'habit' is
quite ungrounded."
Personally, I think it possible, one such case having been
under my care — a patient who used one pound of fluid extract
of coca every two days. The gentleman recovered.
Dr. Bauduy's enthusiasm regarding cocaine may be the
legitimate outcome of his experience with it in various dis-
orders, but, in placing before the profession the conclusions lie
has reached, I respectfully submit that the one regarding its use
in opium addiction belongs among those " not sufficiently ma-
tured by time and experience."
J. B. Mattison.
PUERPERAL DIPHTHERIA.
168 West Twenty-third Street, September 30, 1885.
To the Editor of the New York Medical Journal :
Sir: In your otherwise excellent report of my paper, read
before the American Gynaecological Society, two errors have
occurred, which you would oblige me by correcting — the more
so as one of them might be of practical importance. "The pa-
tient complained of pain in the epigastrium " should read The
patient complained of pain in the hypogastric region. The sup-
positories I have used contained a hundred grains of iodoform.
Yours truly,
H. J. Gareigues.
NEW YORK ACADEMY OF MEDICINE.
Meeting of October 1, 1885.
The President, Dr. A. Jaoobi, in the Chair.
The President's Address was published in our last issue.
Obscure Cases of Weak Heart.— Dr. R. Van Santvoord
read a paper on this subject, in which he said that weakness of
the cardiac muscle, occurring independently of valvular lesion,
was recognized as an important pathological factor in a large
number of morbid conditions. It was a chief source of danger
in acute febrile diseases; it occurred as a result of continued
anaemia, and of alcoholism and other toxic conditions. Failing
cardiac compensation was often the cause of death in chronic
Bright's disease. The right ventricle was frequently affected in
lung diseases which interfered with the pulmonary circulation.
Defeneration of the cardiac muscle might result from inflamma-
tion in the course of general diseases, or as a result of lesions of
the coronary vessels. Strain might weaken the heart. At the
Oct. 10, 1885.]
PROCEEDINGS OF SOCIETIES.
413
autopsy there might be found granular, fatty, fibroid, or waxy
degeneration. The heart structure might be found normal, al-
though the history during life pointed to cardiac failure as the
cause of death. In many of these conditions the diagnosis could
easily be made, but in others the connection between the symp-
toms and the cardiac failure was obscure and liable to be over-
looked.
Dr. Van Santvoord then proceeded to relate four histories of
obscure cases of weak heart, and to study the significance of the
symptoms which were present. The first case was that of a
slightly corpulent man of forty-two years, who was apparently
in robust health. He drank but little. Sleepiness was the
symptom of which he complained — he fell asleep frequently
during the day; and he was forgetful, and complained of head-
ache. There was slight dyspnoea on ascending stairs. The only
evidence of organic cardiac derangement was that the sounds,
especially the first, were rather weak, and reduplication of the
second sound was to be heard at the base of the heart. The
symptoms dated back two years, when the patient had a severe
attack of pneumonia. The diagnosis of weak heart following
pneumonia was made. The treatment consisted in the adminis-
tration of tincture of digitalis and tincture of nux vomica, the
latter for indigestion. After two weeks the heart sounds be-
came louder, but the patient was not apparently improved.
Five grains of citrate of caffeine after meals were given in the
place of digitalis, and one thirtieth of a grain of strychnine
instead of nux vomica. The heart sounds soon became louder,
and the disagreeable symptoms disappeared. When he was last
seen, twenty-three weeks after the beginning of the treatment,
the patient was in a comfortable condition, though slightly short
of breath. There was persistence of reduplication of the second
sound of the heart, heard at the end of inspiration and the be-
ginning of expiration.
The second case was that of a stock-broker, aged thirty-
eight years, who had had a number of slight attacks of gout,
and several of whose relatives were gouty. He had been wor-
ried about business, and had drank freely. He had been short
of breath ; had had albumin in the urine ; his ankles were puffy,
especially after drinking brandy. He drank freely and ate lit-
tle. One relative was asthmatic. The author had been called
to him on account of dyspnoea and wheezing. He found the
dyspnoea slight, the lungs normal ; the first heart-sound weak,
the second metallic and hard ; not quite clear. The tongue was
coated. He complained of flying pains in the muscles. The
urine contained a small amount of albumin, and its specific
gravity was l-024. After six days' restraint from alcohol, ad-
ministration of proper food, the use of morphine and Hoffman's
anodyne at night, great improvement had taken place. The
symptoms, however, returned when he began again to go about;
the apex-beat was weak, the pulse was 102, and there were oc-
casional pains shooting from the apex to the scapula. Digitalis
and remedies for the condition of the bowels were administered,
and within two days the pulse fell to 84, and its tension in-
creased. He was restrained from alcohol, and after six months
was greatly improved and in comfortable general condition.
The first heart sound was still short and valvular, the second
metallic and sharp, the arterial tension low, the pulse 82. The
urine contained a small amount of albumin and many hyaline
casts. In this case the abuse of alcohol and underfeeding had
caused malnutrition of all the organs, but the rapid and con-
tinued improvement after the use of digitalis, especially in the
cardiac action, was proof that the heart was the organ chiefly
affected. The normal quantity of the nrine, the small amount
and inconstancy of the albumin, the absence of evidence of ac-
tive kidney trouble, the low tension of the pulse, and the rapid
improvement went to prove that the albuminuria was probably
not associated with grave organic changes in the kidneys. The
lesion in this case was conjectural ; from the fact of the abuse
of alcohol it might be inferred that there was fatty heart, but
the rapid response to digitalis pointed to a less grave state of
malnutrition. There was persistent irritability of the heart,
due apparently to mental worry.
The third case was that of a man, aged fifty-four, who had
been addicted to out-door sports. His health had always been
good except for constipation. His illness began, some months
before he consulted Dr. Van Santvoord, with lassitude, drowsi-
ness, and distressing headache, chiefly at the vertex. He had
for a long time been obliged to get up at night to urinate. Dr.
Van Santvoord was consulted for an unusually severe attack of
pain in the vertex and back of the Ifead. The man was thin,
sallow, and anxious; the tongue slightly coated ; the appetite
good. The apex of the heart was in the nipple line, in the sixth
interspace, and at that point there was a faint systolic murmur.
The cardiac sounds were weak. A mixture was given to correct
the condition of the stomach, with the idea that the head symp-
toms were reflex, hut no benefit followed. Faradization alone
produced an effect upon the bowels. Ten minims of tincture of
digitalis and twenty of tincture of chloride of iron were ordered,
and during twelve days the heart sounds continued to increase
markedly in force, the pulse became stronger, and the general
condition improved very decidedly. The urine continued to be
passed in large quantity; it contained no albumin or sugar; a
few pus -globules were always present; its specific gravity
ranged from 1-0105 to 1-0195. The patient had been treated
for stricture, and had seminal emissions. From the enlarged
heart and the great quantity of urine passed it was thought that
he was suffering from contracted kidneys, with secondary heart
failure, although the specific gravity of the urine was usually
normal and it contained no albumin. The man went South, and
remained in fair health. A year afterward he was a little short
of breath, and had an indefinite disagreeable sensation in the
head and occasional shooting pains in the arms and legs. The
apex of the heart was in its former situation ; the heart sounds,
especially the second, were weak, with a reduplication of the
first to the left of the sternum and on a level with the fourth
rib. The sphygmographic tracing was of large amplitude, the
tidal wave more marked, the aortic notch much higher in the
tracing, and the dicrotic wave far less developed than in the
case of the second patient. The pulse was 75. Digitalis and
fluid extract of ergot caused, within ten days, diminution in the
amplitude of the pulse, lessening of the dicrotic wave, and
lowering of the pulse to 64. The sphygmographic tracing now
differed from a normal tracing only in showing a little lower
tension. The urine had a specific gravity of 1015 : it contained
no albumin, and but few pus and red blood-globules. The fact
that the patient had held his own for a year, the specific gravity
of the urine being normal for the amount passed, and that the
sphygmographic tracing showed low arterial tension, led to the
conclusion that the polyuria was due to some other cause than
contracted kidney, being possibly a reflex result of the urethral
lesion. The cardiac failure, therefore, seemed to be an inde-
pendent matter. The age of the patient pointed to an early
stage of one of the chronic degenerative processes. His addic-
tion to athletic sports suggested the weak dilated heart, without
recognizable histological change, noticed by Munzinger.
The fourth case was mentioned only on account of certain
special features. A boy, aged fourteen, had a severe attack of
measles. His previous health had been good. After convales-
cence he suffered from dyspnoea and lancinating pain in the car-
diac region on running. He was thin and pale; the cardiac
beat was marked over the apex, in the epigastrium, and second
left interspace, and both ventricular areas were enlarged. The
414
PROCEEDINGS OF SOCIETIES.
[N. Y. Meo. Jotr.
heart sounds were loud. There was distinct reduplication of the
second sound in the third left interspace, near the sternum. A
loud, hlowing systolic murmur was heard over the arteries at
the hase of the neck, transmitted into the brachials and femorals.
Improvement took place under the use of iron, strychnine, and
rest; the dilatation of the heart diminished, the arterial mur-
mur disappeared, and the venous hum became lessened, but the
reduplication of the second sound persisted. The absence of
cardiac murmur and the rapid improvement pointed to cardiac
dilatation, with perhaps some fatty degeneration.
On reviewing the symptoms in these cases it would be seen
that reduplication of one or other of the heart sounds was pres-
ent in three of them. The cause of this phenomenon had been
much discussed, but the simplest explanation was, that the re-
duplication of the first sound was due to asynchronism in the
contraction of the ventricles, while that of the second was due
to asynchronism in the closing of the aortic and pulmonary
semilunar valves. Bramwell thought this the explanation in
the majority of cases. Apart from purely theoretical specula-
tions, which the author reviewed, it was a fact that persistent
reduplication of the first sound had been found clinically associ-
ated with functional disorders and with grave organic changes
of the heart, with or without valvular disease. It was at least
within the limits of our present knowledge of the subject to say
that its presence in a given case was presumptive evidence of
cardiac lesion, the character and gravity of which would have
to be determined by the other symptoms. As to reduplication
of the second sound, it might be due either to derangement of
the nerve apparatus or to lesions of the muscular fibers of the
heart which caused the contraction of one ventricle to be a little
shorter than that of the other, or to disturbances in the relative
amount of resistance to be overcome by the respective ventri-
cles. Aside from theory, as a matter of clinical observation,
reduplicated second sound was so frequently associated with
obstruction to the greater or lesser circulation, with lesions of
the cardiac muscle, or with a combination of both, that its oc-
currence should lead to a careful study of the case with a view
to determining the presence or absence of important cardiac dis-
ease. In the case of weak heart following pneumonia, the redu-
plication of the second sound was heard when last listened to
only at the end of inspiration and the beginning of expiration —
i. e., it was of the normal type. The patient's condition at the
time was comfortable, and an observer who knew nothing of
his former history might wrongly have concluded that the sign
was without significance. Regarding the weak first sound, in
interpreting the meaning of a short, weak valvular first sound,
it was obvious, from a study of the sphygmographic tracing in
these cases, that the peripheral resistance to the circulation was
quite as important a factor as the strength of the ventricular
contractions. But in interpreting the meaning of a strong or a
weak second sound we should consider not only arterial tension,
but also the form of the ventricular contraction. The author
felt convinced that closer observation and analysis of the less
striking evidences of deranged cardiac action would greatly les-
sen the number of cases of grave cardiac lesion which remained
totally unsuspected before an autopsical examination. Regard-
ing the effect of digitalis and caffeine, it was plausible to sup-
pose that the contrasted effect of the two remedies in the cases
related might lie in the slighter influence of caffeine on the vaso-
motor apparatus. At any rate it would be seen that caffeine
was sometimes efficient when digitalis failed. The greater safety
and more rapid action of caffeine would make it preferable to
digitalis in cases of heart failure occurring in acute diseases or
primary degenerative processes of the cardiac muscle. The
soluble and stable combinations of the alkaloid with salicylate
or benzoate of sodium were preferable to the insoluble and un-
stable citrate. It should be given in divided doses, first small,
and pushed as high as half a drachm daily.
The subject of the paper was discussed by Dr. John C. Pe-
ters, Dr. L. Weber, Dr. E. D. Hudson, Dr. A. H. Smith, and
others.
PHILADELPHIA CLINICAL SOCIETY.
Meeting of September 25, 1885.
The President, Dr. Edward E. Montgomery, in the Chair.
Mary Willits, M. D., Reporting Secretary.
A Case of Empyema.— Dr. I. G. Heilman reported the case
of E. M., aged nine years. His family history indicated some
tendency to pulmonary disease, but his health had always been
good. Dr. Heilman was called to see him on April 24, 1885,
and found him suffering from an attack of measles. The case
presented nothing unusual until April 29th, when pneumonia,
limited to the lower lobe of the left lung, set in, and the case
became more serious. May 1st he was hastily summoned, and
found the patient suffering with intense pain in the left side of
the chest, and exceedingly nervous. The symptoms suggested
pleurisy, which the physical signs showed to be present. An
opiate, with counter-irritants, afforded relief ; but on the follow-
ing day there was a decided effusion, which continued to in-
crease in quantity until it filled the entire pleural cavity on the
left side. Respiration being entirely suspended on that side,
the dyspnoea was very great. The temperature varied between
102° and 103° F. The acute symptoms gradually abated, but
there was very little decrease in the quantity of effusion. By
May 13th, two weeks after the beginning of the attack, the pa-
tient seemed fairly comfortable, the temperature varying be-
tween the normal and 99-5° F. On measuring the chest the
affected side was found to be one inch larger than the other.
The percussion-note was still non-resonant; respiration sounds
and movements were absent. Absorption seemed to have begun,
when the patient's stomach became so irritable that scarcely
any nourishment could be given for a week; the effusion again
filled the left pleural cavity, and, in spite of quinine, potassium
iodide, Basham's mixture, and hydragogue cathartics, with tinc-
ture of iodine and cantharidal collodion externally, the patient
gradually grew worse. The temperature, however, during this
period never rose above 100° F., nor the pulse above 95, except
temporarily after exertion, or following an attack of nervous-
ness. On June 19th Dr. E. R. Stone saw the case in consulta-
tion, and it was concluded that paracentesis was the only meas-
ure that promised relief. The condition of the patient at that
time was not so serious as to cause the presence of pus to be
suspected. His appetite was quite good; he spent a portion of
each day on the street; he had fever only occasionally, and
slept well. There was dyspnoea, but not to so marked a degree
as would be expected in a case of that character. On June 23d
an aspirating-needle was passed into the pleural cavity and
eighteen ounces of pus were drawn off. No unpleasant symp-
toms attended the operation, and marked relief was afforded ;
the lung expanded, and twelve hours after a good respiratory
murmur was found at the apex. The improvement was but
temporary, and a week later the entire cavity had again filled.
It was then decided to use the aspirator daily, and to remove
as much of the fluid as the patient could bear. To obviate the
necessity of a daily puncture with the needle it was decided to
introduce a tube and to retain it in position. A puncture was
made with an ordinary trocar and cannula, the trocar with-
drawn, and a soft-rubber catheter was passed through the can-
nula, which was then drawn out over the catheter, thus leaving
in the pleural cavity a tube to which the aspirator could be at-
tached at any time. The catheter was held in position by a
Oct. 10, 1885.1
PRO CEEDINQS OF SOCIETIES.
415
strip of adhesive-plaster, and closed by a wooden plug. Aspi-
ration was performed on nine successive days — June 30th to
July 8th — and seventy ounces of pus were drawn off in all,
which, with the first eighteen ounces, made a total of eighty-
eight ounces. The aspiration of July 8th was followed by a
little blood. From July 9th to July 14th a daily trial was
made, but no further discharge took place. On July 11th a
little water was injected, but was immediately forced out be-
tween the chest-wall and the tube. The lung in the mean time
had expanded, and there was an almost normal respiratory mur-
mur over nearly the entire chest, with good percussion reso-
nance. On July 13th water was again injected, with the same
result as before. On the 14th, in consultation with Dr. "W. F.
Buchanan, the tube was removed and the wound was [closed
with adhesive plaster. The left side at that time measured
seven eighths of an inch less than the right side. The condition
of the patient had decidedly improved ; his appetite was very
good and his strength was returning rapidly. He had since
gained ten pounds in weight, had attended school, and taken
part in out-door sports.
Dr. Heilman said that the points of interest in the case were:
1. The length of time (seven weeks) during which the lung was
compressed until the aspirator was first used, in all eight weeks,
before a regular systematic effort was made to remove the pus.
Yet the lung steadily expanded as the pus was removed. 2.
The time (nine days) required for the removal of the entire
quantity of pus; there was no discharge alter that time, and
the tube might have been removed then with safety. 3. No
antiseptic solution was injected — indeed, no attempt was made
to wash out the pleural cavity. It was true that a small quan-
tity of water, not more than two ounces, was injected twice,
but that was done for the purpose of removing any clots that
might have been obstructing the tube. He was aware that that
was not in accord with modern teachings and practice, but it
was difficult to see how antiseptic washings could have hastened
the recovery of the patient. The aspirator in the treatment of
those cases possessed, it seemed to him, so many advantages
that he could scarcely conceive of a case where resort to the old
method of open drainage would be justifiable. The simplicity
of the operation in the one case and its difficulty and gravity
in the other were points worthy of consideration. It was, he
said, a trifling matter to puncture the chest-wall with a small
trocar and cannula ; but in a patient already exhausted it was
often a most serious one to make two large openings and remove
portions of the ribs.
Cleanliness was another point for consideration. In the case
reported not a drop of pus escaped except when the aspirator
was used. There was absolutely no unpleasant odor at any
time, nor soiling of the patient's clothing — both so annoying
when an open drainage-tube was used. A still greater advan-
tage, in his opinion, was the control it gave the physician over
the expansion of the lung, as he could cause it to expand rap-
idly or slowly, at his pleasure. The expansion being a gradual
one, those distressing symptoms that so often resulted from a
sudden removal of the fluid were avoided.
Dr. Heilman then exhibited the patient. The two sides of
the chest resembled each other in contour ; the percussion-note
was the same on both sides, and a recent measurement showed
that the left side was only one quarter of an inch smaller than
the right.
Dr. Collins remarked that he noticed a slight friction-sound
on the affected side, probably due to a deposit of lymph on the
pleural membrane. He thought that if aspiration had been
done earlier there would have been less danger of a deposit.
He considered it an advantage to aspirate early, and would not
hesitate to operate at the end of fourteen days. In regard to
the use of antiseptics, he did not consider them necessary, as
with the aspirator no air entered the pleural cavity.
Dr. Beates said that in his experience the entrance of air
into the pleural cavity had caused no unpleasant symptoms.
Dr. Heilman, in closing the discussion, said that he had used
the aspirator as soon as the consent of the parents could be ob-
tained ; they were very much averse to an operation. The
pleural cavity was entirely filled, and there was some trouble in
finding the intercostal spaces on that account. He thought that
the escape of blood was due to the aspirator.
Tracheotomy in Croup and Diphtheria.— Dr. Edwaed E.
Montgomery read a paper with this title. [It was reserved by
the author for future publication.]
BROOKLYN PATHOLOGICAL SOCIETY.
Meeting of April 23, 1885.
The President, Dr. B. F. Westbeook, in the Chair;
Dr. A. H. P. Leuf, Secretary.
Aortic Stenosis and Regurgitation; Aneurysm of the
Aortic Valves; Mitral Stenosis and Regurgitation.— Dr.
Glentwoetii R. Butler read the following: "The patient from
whom the accompanying specimen was taken was seventeen
years of age, male, by occupation a tow-boy. He entered St.
Mary's Hospital for the relief of an ulcer on the leg of two
years' standing. He gave a history of acute rheumatism in
1878, and of constant exposure and insufficient nourishment.
The ulcer was of traumatic origin, but healed promptly under
proper treatment. After the stay of a month in the hospital he
developed a lobular pneumonia from which he was fairly con-
valescent on April 1, 1885, when symptoms of cardiac distress
led to an examination of the heart. According to his statement
he had always been able to do a good day's work and had never
had any symptom referable to a cardiac lesion. On examina-
tion, the apex-beat was found to be carried below and to the
left of the nipple, with bulging of the precordial space, and
marked impulse in same region extending over a large area.
On auscultation, a to-and-fro murmur was heard at the base
over the aortic valves, and an apical systolic murmur, all three
well marked. In addition, a faint presystolic murmur was de-
tected over the area of mitral obstructive murmurs. A diag-
nosis was made of aortic and mitral obstruction and regurgita-
tion with hypertrophy of the left ventricle. The after- progress
of the case was rapid, dyspnoea and weakness increasing until
death occurred on April 12, 1885. The lesions disclosed at the
autopsy were as follows: The heart was greatly enlarged, and
the increase in size was particularly in the left ventricle, which
was dilated to at least twice its normal contents. The left
auricle was greatly dilated and its walls thickened. The endo-
cardium was thickened and opaque. The cusps of the aortic
valve were also thickened and opaque. The posterior cusp was
considerably stretched, forming an aneurysm. Large masses of
vegetations were growing from all the cusps. There was a
mass of vegetations on the wall of the ventricle one quarter of
an inch below the aortic valves. The vela of the mitral valve
were thickened and adherent, making a funnel-shaped contrac-
tion of the orifice. The tendinous cords were thickened and
shortened. The papillary muscles were lengthened. The right
side presented no marked changes, which is singular in view of
the extensive lesions on the left side. The lungs were dark-
colored at their bases, and showed patches of collapse, but no
sign of an unresolved pneumonia."
Umbilical Haemorrhage. — Dr. W. H. Thayee read a paper
on this subject. [It will be published in full hereafter.]
Four Cases of Tait's Operation.— Dr. Joel W. Hyde read
a paper with this title. [It will be published in full hereafter.]
410
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jouh.,
Dr. L. F. Ceiado asked at what time with reference to men-
struation the author operated.
Dr. Hydk replied that in the last case it was five days after
the flow.
Dr. Ceiado had asked the question for one reason. He had
seen many ovaries removed which he thought were not cystic,
but contained only Graafian vesicles. He failed to see why
these organs should be removed so much. He did not believe
they all were cystic.
Dr. Hyde had intended to operate within a week after the
cessation of the menses. As regarded cysts, in one case he could
not see the ovary, but in its place a cyst of about the size of an
orange. It contained at least a little more than a gill of fluid.
In another case the ovary contained a cyst as large as a small
walnut. Another had oue which was about one third as large
as the ovary itself. In all the cases there was sufficient disease
of the oviducts to justify the operations, regardless of the con-
dition of the ovaries.
Dr. Ceiado believed that extirpated ovaries were usually not
much enlarged, at least so it appeared to him in those he had
9een. He had doubts about many operations being justifiable.
He had had two cases in which he had refused to operate, but
in which it had been done by some one else. One of the ova-
ries he had been able to see, and it had seemed to him to be
normal.
Dr. C. N. Dixon Jones asked if drainage-tubes had been
used. He considered one necessary in Case III, and also thought
that the microscope could easily settle the difference between a
cyst and Graafian vesicle.
Dr. Hyde replied that he had already stated in the paper
that no evidence of a recent peritonitis was discoverable, but
that there were signs of an old peritonitis. The trouble seemed
to be in the kidneys. Drainage-tubes were not used in any
case.
The Peesident said he believed that he could claim the
honor of having done the first oophorectomy in Brooklyn, in
December, 1879. The patient was a domestic about twenty-
eight years old. She had suffered from a gonorrhoea six years
before. The uterus had evidently been inflamed, and remained
bard, excessively tender, and with a contracted cervical canal
and vagina. She suffered from the most terrible dysmenorrhoea,
during the existence of which she frequently became comatose.
All attempts to relieve her for five years had failed. Her health
was broken, she was unable to work, and a constant cough
caused considerable anxiety lest she should have phthisis. The
menstrual intervals became prolonged to from two to five
months. During one or two very severe attacks, accompanied
by all the symptoms of dysmenorrhoea, but without the haemor-
rhagic flow, there had been a slight discharge of blood from
the rectum. The bladder was excessively irritable. She also
had a lump of the size of an English walnut in the right mam-
mary gland. The operation was performed with the idea of
bringing on the menopause. He was assisted by Dr. George R.
Fowler, Dr. F. W. Rockwell, and Professor E. S. Bunker. The
operation was done under the carbolic-acid spray, and the
wound closed with horse-hair sutures. On the second day she
sat up in bed and pulled off her stockings, and on the third or
fourth day she got out of bed, during the temporary absence of
the nurse, and walked across the room to get a drink. By these
proceedings she broke two or three of the stitches, but she
made an excellent recovery nevertheless. Since the operation
she had menstruated three or four times, at intervals of five or
six months, and then the function had ceased. She had im-
proved very slowly, but was now able to work, and had been in
one place for fifteen months. At last accounts she was con-
templating matrimony. It was interesting to note that the
vesical trouble disappeared immediately after the operation, and
that the mammary tumor also vanished. There were no peri-
toneal adhesions. The ovaries were of the natural size, but
contained numbers of small cysts.
Complete Calcification of the Arch of the Aorta.— Dr.
A. H. P. Leuf exhibited a thoracic aorta that was completely
calcified from its origin at the aortic orifice of the heart to the
opening in the diaphragm. Below the diaphragm it contained
large calcareous patches. It had the appearance of an immense
pipe, and was as solid as if composed of a shell of plaster of
Paris and glue. He asked if any one present bad seen a similar
case ?
The Peesident recalled a similar case that had been pre-
sented to the society a few years ago, in which there was also
complete calcification. It was presented by Dr. E. H. Bartley.
The patient had died of inanition.
MEDICAL SOCIETY OF VIRGINIA.
Sixteenth Annual Meeting, held at Alleghany Springs, Tuesday,
Wednesday, and Thursday, September 15, 16, and 17, 1885.
Dr. Bedfoed Beown in the Chair.
( Continued from page 383.)
Thursday's Proceedings.
Treatment of Lacerations of the Os and Cervix Uteri
without Surgical Operation.— Dr. B. Beown, of Alexandria,
read a paper with this title, and said that the value of Emmet's
operation was acknowledged, although it was sometimes risky;
but many women were so situated that they could never enjoy
its benefits. Ten or twelve years' experience with some twenty
cases had convinced Dr. Brown that these patients could be
cured, without a surgical operation, by a simple, painless, safe,
and easy plan of treatment which could be used by any practi-
tioner. The nature of his cases had varied from trifling fissures
to the most severe lacerations, and sterility had invariably co-
existed. Many cases were complicated by cellulitis, localized
peritonitis, subinvolution, metrorrhagia, displacements, procti-
tis, etc. In every case the general health was impaired. There
were peculiar neuralgic pains in all those nerves coming within
the circle of sympathy of the exposed and lacerated nerves of
the os uteri. Thus, the great lumbar plexus manifested its sym-
pathies in the form of constant aching pain in the base of the
sacrum. Ovaralgia on the side of injury, or on both sides, if
the injury was double, was almost invariable. In a few cases
the development of sciatica indicated reflex sensation on the
part of the sciatic nerves. Neuralgia of the crural nerves and
their branches "was common. These pains extended to the
patella, and even down to the dorsum of the foot. Dr. Brown
had healed several cases of laceration by first intention in the
acute stage by means of absolute rest, disinfection, and clean-
liness. If lacerations failed to unite immediately after labor by
first intention, they never united spontaneously by second in-
tention. Local treatment then became necessary. Dr. Brown
always examined the womb, etc., for lacerations as soon as labor
was completed ; and, if found, he began, after the first twenty-
four hours, a systematic course of treatment with a view to
absolute disinfection and cleanliness. Warm douches of solu-
tions of borax, boric acid, and carbolic acid were gently used
two or three times daily, and the patient was kept in the re-
cumbent position for two weeks. If healing did not occur by
that time, it did not occur afterward spontaneously. Eight or
ten weeks later, in such cases, he proceeded to procure union
by the second intention. For this purpose he had used car-
bolic acid, chromic acid, Battey's solution of carbolic acid and
Oct. 10, 1885.]
PROCEEDINGS
OF SOCIETIES.
417
iodine, solid nitrate of silver, and even nitrate of mercury, but
without favorable result. The nitrate of silver increased the
inflammation, pain, and tendency to haemorrhage. He then
adopted graduated solutions of crystals of nitrate of silver with
the best of results. Solution No. 1 was as follows :
5 Argenti nitratis, cryst., 3 ss. ;
Aquae destillat., f§j. M.
This solution was to be applied to the interior of the cervical
canal freely, down to the os internum, as tbe cervical canal was
always involved in the rent and was left in a diseased condition.
Solution No. 2 was :
5 Argenti nitratis, cryst., 3ijss. ;
Aquas destillat., f § j. M.
This solution was to be applied with a camel's-hair brush freely
over the entire external surface of the os and cervix, including
the fissure of the laceration, until a uniform white coating was
formed, thick and tenacious, almost resembling a coat of paint.
This gave immediate protection to the supersensitive extremi-
ties of the exposed nerves and tender granulations, and acted
as a sedative application — allaying irritation, redness, inflamma-
tion, and engorgement rapidly, stimulating new vital action and
healthy growth of granulations which filled up the fissures or
cavities of the lacerations, and accomplished the healing of the
wound by second intention. This coating, in the mean time,
formed an impervious barrier to tbe further absorption of septic
matter from the discharges, and in this way relieved pelvic cel-
lulitis. Tbe healing process and reduction of hypertrophy of
the cervix and inflammation progressed rapidly. The process
of absorption was stimulated in a wonderful manner, and the
process of involution was also promoted in proportion. In sim-
ple fissure of the cervix, extending through the mucous mem-
brane and fibrous tissue only partially, solution No. 1 should
be applied thoroughly in flie groove of the fissure, so as to
reach its very bottom, and thus induce healing from the lowest
depths of the wound ; otherwise the object would be defeated.
Solution No. 3 was :
B Argenti nitratis, cryst., 3 jss. ;
Aquae destillat., f § j. M.
This solution was only to be applied to the external surface
of the cervix in the event hypertrophy and induration remained
after the lacerations had healed ; otherwise, if left in that con-
dition, it formed a basis for the renewal of inflammation and
re-opening of the wound. After treatment, the cervix became
naturally soft and normal in dimensions. The os was not only
not contracted by tbe application, but returned to a perfectly
healthy condition. A great majority of females thus treated
had since borne from one to three children, and had been en-
tirely free from all uterine troubles. In three patients — one
having borne three children, the second two, and the third one
child after treatment for previous lacerations — the os uteri was
found perfect as to softness, dimensions, and freedom from dis-
ease. Concealed fissures were often found after labor in the
mucous membrane of the cervical canal, and caused an infinite
amount of local disease, such as endocervicitis, hypertrophy of
the adjacent tissues, inflammation of the fibrous tissues of tbe
cervix, leucorrhcea, and often painful menstruation. A favorite
locality for these fissures was at the internal os. The mucous
membrane and submucous tissue were split through, and then
the rent remained a source of trouble for years. The No. 1
solution of nitrate of silver reached these wounds admirably,
and would surely heal them from the bottom.
Puerperal Septicaemia especially with regard to Pro-
phylaxis and iEtiology.— Dr. George T. Hauuison, of New
York, read a paper with this title. Due credit was given to the
labors of Semmelweiss for his valuable investigations, which
pointed out the right road to the study of puerperal fever. He
showed that childbed fever was a disease that came from with
out. Without a wound somewhere along the genital tract,
puerperal septicaemia did not exist. After expulsion of the
child and secundines in labor, the entire inner surface of the
uterus was laid bare, like a part of the skin deprived of its epi-
dermis by a blister. With this fact it was only necessary to call
to mind the possibility of very rapid absorption of septic mat-
ters introduced into the vagina or the uterus. In primiparae
always, and in multiparas generally, there were tears in the cer-
vix, vagina, and vulva, and often lacerations or contusions of
the perinaeum. If a puerperal wound were protected from ex-
ternal influences it would heal like a wound on the surface of
the body. But putrefactive organisms could develop in the liv-
ing organism wherever dead tissues or fluids (as extravasated
blood) were found, while the healthy physiological tissue in
general opposed a considerable resistance to their multiplica-
tion. On the other hand, other pathogenous (disease-generat-
ing) micro-parasites find in the living tissues in the cells, in the
blood, in the lymph-sinuses, etc., the favorable condition for
development and multiplication. These fungi, endowed with
specific powers, were entirely different from the putrefactive
organisms, and were destroyed by the latter. In puerperal
fever tbe carriers of infection were either the pathogenous
fungi, which generated traumatic diphtheritis, pyaemia, and
septicaemia, or they were putrefactive germs. The latter were
ubiquitous; the former were imported, and got to the puerperal
woman by the hands, instruments, cloths, etc., that might be
used about the genitals. They were derived from suppurating
surgical wounds, cadaveric poisons, and especially lochia! dis-
charges of women suffering with septic infection. A minimum
quantity infected in the effective manner. The lochial dis-
charges of puerperal sick during an epidemic were so infectious
that they endangered life, by infection, of the non-puerperal
woman to the pregnant, to physicians, and gynaecological cases
where operations had been performed. In the puerperal wo-
man the conditions for the rapid development of pathogenous
fungi were most favorable. Contrary to general opinion, Gusse-
row had shown that there was no connection between puerperal
sepsis and erysipelas, and that the micrococci of erysipelas could
not produce pathological changes identical with septic processes-
The pathogenous fuugi affected the organism immediately, while
putrefactive germs did so indirectly by their influence on de-
composable matters, always present in puerperal women. An
autogenous or autochthonous infection was an impossible thing.
The characteristic features of non-pathogenous infection were (1)
the late appearance of the fever, (2) tbe slight participation of
the general condition, and (3) the existence of local morbid sub-
strata. The principles of prophylactic treatment consisted in
pure air for the lying-in woman, the careful avoidance of intro-
duction of infectious matter into the genital passages, and the
thorough disinfection of the genital tract. The physician's and
the midwife's hands, instruments, etc., should be disinfected be-
fore using about a puerperal woman. Disinfection must be both
mechanical and chemical. Use the finger-nail brush often, thor-
oughly washing the hands with soft soap, and then wash the
hands again. Take off the coat and roll up shirt-sleeves. Then
dip the hands and forearms in a disinfectant solution. Instru-
ments and cloths should be dipped in about a five-per-cent. solu-
tion of carbolic acid for several minutes. During the preg-
nancy, especially if there be any puerperal-fever epidemic, the
woman should frequently wash her external genitals with soap
and water, and afterward with boric-acid solution. When labor
set in, Dr. Thomas advised her to use a warm vaginal injection
of antiseptic character, but Dr. Harrison protested against the
injection under ordinary circumstances, as such injections were
418
PROCEEDINGS
OF SOCIETIES.
[N. Y. Mkd. Jodh.,
unnecessary and fraught with danger. They removed the mu-
cus which rendered the vagina soft and pliable, and most of
the disinfectants used, especially carbolic acid and mercuric
bichloride, coagulated the mucus and irritated the surface of
the vagina. The bacteria naturally found in the vagina were
not dangerous. But, if the patient had been subjected to the
possibility of septic infection during the birth, then it would be
eminently proper to use a copious antiseptic vaginal douche im-
mediately after the birth and during the rest of the puerperal
state. In tedious and complicated labors, where frequent ex-
aminations had to be made or instruments used, infections were
absolutely indicated. Sometimes putrefactive decomposition of
the uterine secretions occurred before labor ended. In such
cases, complete the labor as speedily as possible, and thoroughly
disinfect the genital tract by intra-uterine injections of carbolic
acid or mercuric bichloride. Wash the external genitals three
or four times daily, and disinfect once a day by carbolic acid or
mercuric-chloride solution. Close all lacerations of the peri-
neeum and vagina under strict antiseptic precautions, as by the
continuous catgut suture. Iodoform dusted over the raw sur-
face favored union. A powerful contraction and retraction of
the uterus greatly helped in securing immunity from invasion
of putrefactive bacteria; hence the value of Crede's method in
expelling the placenta.
A Report on Advances in Surgery was read by Dr. EL Grey
Latham, of Lynchburg, Va., who summarized the discussion
last spring before the American Surgical Association on uThe
Field and Limitation of Operative Surgery of the Human
Brain," disapproved of extirpation of the larynx and trachea,
spoke favorably of drainage of the lungs for gangrene, etc.,
and said that laparotomies for many purposes were now estab-
lished operations — such as for strictures of the intestines, stran-
gulations, excisions of organs non-essential to life, etc. Do not
wait too long, he said, in strangulations of the bowels; operate
as soon as the diagnosis is established, as soon as vomiting sets
in. Cut down so as to reach the caecum. If this is distended,
the obstruction is below ; if it is collapsed or not tense, it
is above. If the strangulated coil of bowel is gangrenous,
resect it, and establish an artificial anus. When laparotomy is
rejected, adopt Nelaton's enterotomy in the right iliac fossa.
Dr. Latham laid dovyn as propositions (1) that the best guide to
the seat of an obstruction was not manual exploration, but
visual examination, assisted, if necessary, by extrusion of the
bowels, and (2) that no case of operation was properly concluded
until an over-distended bowel was relieved of its contents. In
operations for hernia, invagination had been laid aside or neg-
lected, and obliteration of the sac or closing the neck was the
popular procedure. Digital dilatation of the pylorus had been
successfully performed for chronic non- malignant stricture.
Through an incision into the stomach introduce a finger, and
forcibly distend the stricture. In operative treatment for rectal
cancer the following guides were said to be reliable: (1) If the
finger can not be passed beyond the disease, unless it is confined
to the posterior wall, do not operate. (2) The growth can be
removed at a somewhat greater height when the disease is con-
fined to the posterior wall. (3) If, when the finger has passed
beyond the disease, the bowel is movable on the adjacent struct-
ures, generally speaking, the growth has not extended beyond
the rectal walls, and the case is suitable for operation ; but, if
the bowel feels hard, rigid, and firmly bound to the surround-
ing organs, the case is unfavorable for an operation. (4) Ex-
amine carefully the abdominal viscera, and, if secondary de-
posits be suspected in the liver, no operation should be per-
formed.
Advances in the Practice of Medicine.— The committee,
through its chairman, Dr. Rives Tatum, of Harrisonburg, Va.,
reported some of the progress made in the healing art during
the year. The subject of cholera, in view of its probable visi-
tation to the United States next year, received due considera-
tion. The comma bacillus was still mb judice as an serological
factor, while its constant presence in all cases of genuine Asi-
atic cholera seemed to be admitted by all competent observers.
Dr. Ferran, of Valencia, Spain, still practiced his system of in-
oculation to prevent cholera. His methods were pronounced by
the various commissions engaged to investigate the matter as
questionable, and the results as equally uncertain. In view of
the fact that one attack of cholera did not prevent a subsequent
attack, the principle of vaccination in this disease was likely
to result in a failure. The new local anajsthetic, cocaine, had
been found of signal service in the treatment of hay fever, used
both locally and internally. The mercurial treatment of typhoid
fever and diphtheria received due attention in the report, which
claimed for the method a reduction of mortality in both dis-
eases. The report claimed the unity of scrofula and tubercu-
losis, and called attention to peptones and mucin in the urine
as interfering with tests for albumin. It alluded to the toxic
alkaloids found in the body (ptomaines) as a possible cause of
morbid processes, and closed by allusion to the new drug, anti-
pyrin, giving a synopsis of its therapeutic indication and physi-
ological action.
Clinical Notes on Carcinomatous Affections of the Diges-
tive Organs; the Unreliability of Gastric Symptoms as
Evidences of Gastric Pathology, was the title of a paper by
Dr. R. C. Powell, of Alexandria, Va. He started off with a
description of cancer, clinically considered, and reported several
cases showing the obscurity of diagnosis. The cases illustrated
two points of diagnostic importance: (1) Unreliability of gastric
symptoms as evidence of gastric disease, and (2) the great value
of cachexia as corroborative evidence of malignant disease. Dr.
Powell regarded the cachexia as a more certain sign of cancer
than the presence of a tumor. As to treatment, the indications
were to sustain strength and to relieve pain. A judicious selec-
tion of food was necessary if the stomach be involved. Fatty,
saccharine, and starchy foods were digestive chiefly in the in-
testines, and hence were best when the stomach was diseased.
If the pancreas was the diseased organ, give meals, albuminoid
substances, milk, etc., which were digested in the stomach ; but
all food should be pancreatinized before it was used. If the
liver was the diseased organ, allow both meat and fish, but not
salted nor highly seasoned. Salt-water fish were believed to be
best. Fruit and vegetables — raw or cooked as preferred — were
allowable. Permit " amusement without excitement, exercise
without fatigue, and nutrition without stimulation." To relieve
pain and procure sleep, use opium or morphia. Fowler's solu-
tion combined with bichloride of mercury ; carbolic acid and
tincture of iodine — one drop each — and bismuth subnitrate, were
the commonly used medicines. When bismuth was combined
with atropia, it was useful in the salivation of cancer. Cun-
durango and Chian turpentine had passed into oblivion, and
alveloz would soon also be forgotten.
The iEtiology of Zymotic Diseases was the title of a paper
by Dr. M. A. Kust, of Richmond, Va. He first reviewed the
evolutionary history of the bacteria from their discovery by
Leeuwenhoek, in 1682, to the present time. The germ theory
was evolved from the fermentation theory — the morbid process of
zymotic diseases being regarded as analogous to fermentation —
the contagium playing the role of the leaven, exciting fermenta-
tion in the blood and humors of the body.
When Liebig appeared with his fascinating physico-chemical
fermentation theory, his application of it to explain the morbid
process of zymotic diseases was generally accepted, and for a
long time his theory kept the yeast-plant — which, since its first
Oct. 10, 1885.]
MISCELLANY.
419
discovery by Leeuwenhoek, had been repeatedly discovered, for-
gotten, and re-discovered — in the background. When, finally,
mainly through the efforts of Pasteur, the yeast-plant was uni-
versally recognized, the medical mind, dropping Liebig's the-
ory, came to the conclusion that, if the active principle of fer-
mentation was a living organism, the contagium of zymotic dis-
eases must also be living matter.
Thus the germ theory was ready to spring into life; its way
could never have been paved by practical medicine or clinical
observations; the pathfinders were botanists, biologists, etc.,
who, by their researches and experimental studies concerning
the aetiology of certain epidemic diseases among plants and in-
sects, disclosed in every instance, as the incontrovertible primary
cause of the disease, the action of some low form of life. Dr.
Kust then gave a detailed description of the silk-worm plague
«nd its stay by Pasteur. It now stood clear before the minds
of the young medical generation that similar organisms must
be found as the primary cause of the infectious diseases of mam-
malia— man included. And they were found at first, perhaps,
in too great redundance for the credit of the theory.
Dr. Kust divided the microbes into three classes : Those
which were undoubted, those of questionable character, and
those whose existence was placed by induction and analogy
almost beyond doubt.
The rapid progress made within the last decennium justified
the hope that all remaining obscurities as to the relation be-
tween microbes and disease would soon be elucidated.
After this, however, there still remained three perplexing
questions :
First, Whence came these numerous species of microbes?
The view hitherto entertained that miasms or germs were
held in suspense by the air we inhale or by the water we drink
wa» held by Dr. Kust to be fallacious. Any substance present
in the air of a locality must have its source in the soil beneath
or emanate from an object on the soil, whence it was continu-
ally renewed; and what the water contained in solution or
suspension was also derived from the surrounding soil, or had
found its way into it from without. The soil from the surface
down to a considerable depth was the habitat of the bacteria,
whence they arose in the form of the finest dust.
Not from the streets of our over-filled cities (provided they
were broad enough to give free access to sunshine) arose this
dust; it arose from the soil into our crowded, unventilated
houses as the smoke from the hearth was drawn up into the
chimney. No amount of sanitary measures hitherto devised
would save a densely populated city from dying out in two or
three generations (unless filled up by immigration) so long as
the modern architect was allowed full sway.
Dr. Kust discussed the various views advanced concerning
the transmutability of bacteria, the change from the specific
into th« non-specific form, and vice versa, and held that our
present state of knowledge admitted neither affirmation nor de-
nial.
The second question was, How does the morbid process of
bacterial disease ever come to a happy end?
Since the development of the germ theory we had arrived
at the perception that we had to reckon with two factors : the
cellular- resisting power on the one hand, the degree of virulence
and the numbers of the invading microbes on the other. The
numbers were of the greatest importance. If a few microbes
were sufficient to generate disease, what would happen to the
doctors who were daily and hourly exposed to their onslaught?
Infection or immunity, abortive or fully-developed form of
the disease, recovery or fatal end, were the resultants of the
Correlation between cellular-resisting power and the intensity
and numerosity of the invading microbes.
But how should we physiologically conceive this cellular-
resisting power ? On this point we were still in the dark. A
gleam of light was, however, dawning in the distance.
The white corpuscles, leucocytes, or migratory cells which
circulated in the blood and were to be met with in every multi-
cellular organism, constituting the blood of the white-blooded
animals, and being present in the tissues of the lower animals
which had no vascular system — these leucocytes, identical with
the amoeba found in all stagnant waters, had formed the object
of the particular studies made by Dr. Metschnikoff, of Odessa,
lie could only make his experiments on animals (Bipinaria, As-
teridse, etc.) which were of such exquisite transparency that
all occurrences within the living animal could be accurately ob-
served from without. Just as one saw the amoeba eating under
the microscope, Metschnikoff could observe through the trans-
parent teguments of those animals the leucocytes eat up all
foreign bodies. It seemed that, by the division of labor in the
multicellular organism, these leucocytes (which Metschnikoff
had named phagocytes — eating-cells) had assumed the task of
eating up all heterogeneous and waste matter, and eliminating
what they could not digest.
The question now arose whether the phagocytes, if they ate
up all foreign bodies, would not likewise eat up intrusive mi-
crobes ?
The experiments hitherto made by Metschnikoff seemed to
answer in the affirmative, and, should these experiments and
observations prove conclusive, recovery or fatal end of the dis-
ease would depend on the proportion between the number of
the phagocytes and the number of the microbes. The impene-
trable mystery of the cellular-resisting power would hare re-
solved itself into a prosaic, tangible eating power. The third
question was, How was immunity effected through vaccination?
There were numbers of untenable, explanatory theories in
the field. Instead of descanting upon them, as was his inten-
tion, Dr. Kust referred to the exhaustive criticism of these theo-
ries by Dr. Sternberg, U. S. Army, which appeared in the
London "Lancet," June, 1885. In his explanation of immu-
nity Dr. Sternberg rightly assigned the first rank to vital power,
but the causative relation of vaccination to immunity still re-
mained unexplained.
While Metschnikoff's eating-cells brought a solution, minds
prone to speculation might, even at this early hour, be led to
advance the following theory: That the first meal of microbes
eaten by the phagocytes might prove so acceptable that in
future they would always be ready to consume any reasonable
number of the same kind of microbes that might present them-
selves ; and this theory would rest on foundations possibly more
solid than those of any other theory concerning vaccination as
yet in the field.
( To be concluded.)
l$t t s 1 1 11 a n p .
The International Medical Congress. — The " Canada Medical and
Surgical Journal " says :
" The new committee met in New York early last month and pro-
ceeded to do the best they could with the class of professional material
at their disposal. The nominations of new presidents of the sections
seem, in the majority of instances, most extraordinary. We are near
enough to the States, and familiar enough with American literature, to
know pretty well the names of the leaders in the different departments
of medicine and surgery, but of the seventeen names of chairmen of
sections there are twelve absolutely unknown to us as representatives
4^0
in their different departments. We ask of many, in blank astonish-
ment, Who are they ? What have they done ? Where do they live ?
Truly the committee is sunk low when it must place such men at the
head of important sections in an international gathering. The con-
trast between some of the past and present nominees would be simply
ludicrous, were it not painful. The association is determined to have
the Congress, and the remnant of distinguished men such as Flint, N.
S. Davis, and Dalton, who have cast their fortunes with it, may do
much to save it from being an absolute failure, but the leaders of the
profession, and the workers who have made American medicine and
surgery known here and in Europe, are not in it. The play will go on,
but with Autolycus disguised as Hamlet."
When the foregoing was written, our contemporary was of course
not aware that Dr. Dalton had declined to hold the position to which he
had been nominated.
The " Canadian Practitioner " says :
" The new committee met in New York, September 3d, and made
some concessions to public opinion, though not so many as we hoped
to see. They amended the rule of membership so as to give represen-
tation to societies in special departments, and allow the so-called new-
code men to become members of the Congress without the privileges
of holding any offices. There was apparently no direct effort made to
bring back the eminent men who have withdrawn from the organiza-
tion. Until this is done it is hardly possible for the proceedings of the
committee to command the respect and confidence of the medical world,
which is looking on with fear and trembling.
" Among the most important acts of the last meeting was the elec-
tion of Dr. N. S. Davis, of Chicago, to the office of Secretary-General.
This will meet with general approval. The committee will get a fair
support in New York, particularly from the Bellevue men. The name
of Austin Flint, Sr., will be worth much among the shattered fragments
that remain. Many able men in different parts of the Union will
assist. We may derive what comfort we can from these considera-
tions ; but, after all, the broad, sad fact remains that the cream is prin-
cipally gone, and we are left to feast on skimmed milk."
The Proposed New National Medical Association. — Commenting
on the proposal to form a new national medical association in the United
States, the "Canadian Practitioner" says: "It has been proposed to
organize in the United States a medical association, corresponding to
the Zurich Academy of Medicine, limited in numbers, and so honorable
a body that membership in it would carry the highest reward that
American physicians would have to hope for.
" The proposal, which is heartily indorsed by the ' New York Medi-
cal Journal,' has been made on account of the unpopularity of the
American Medical Association. Its position has not been strong for
years, but its recent action at New Orleans has capped the climax, and
the consequence is that a strong feeling prevails that this association
' must go ' if it be not thoroughly reorganized."
A New Physical Sign of Tricuspid Regurgitation. — Dr. W. Pas-
teur, of the Middlesex Hospital, London (" Lancet "), says : " In several
cases in which there was reason to suspect functional incompetence of
the tricuspid valve which have recently come under my observation, a
physical sign has been present to which I believe attention has not been
drawn, and of which I have been unable to find any mention either in
the standard text-books or in the best known monographs on the sub-
ject of cardiac disease. This sign consists in a distension — with or
without pulsation — of the superficial veins of the neck, occurring when
firm pressure is exerted over the liver in the direction of the spinal col-
umn, and independent of the movements of respiration. A little con-
sideration of the anatomical relations of the parts concerned will sug-
gest the facility with which an impediment may be created to the flow
of blood, in either direction, through the vena cava inferior by such a
manoeuvre, especially when the liver is obviously enlarged. It seems
to me that the state thus produced is virtually that which obtains as a
chronic condition in long-standing and severe cases of tricuspid incom-
petence as far as regards the tension in the systemic venous system
in the immediate vicinity of the heart. Assuming the existence of tri-
cuspid regurgitation and of a source of compression of the vena cava
inferior, it is obvious that with each systole an excessive reflux of blood
(N. Y. Mkd. Jocb.
must take place into the vena cava superior and its tributary veins. It
may be noted that the question of pulsation, as compared with disten-
sion or undulation, is merely one of degree of morbid venous tension.
Although the number of cases in which I have observed this phenome-
non is certainly limited, I have never failed to elicit it when there was
indubitable evidence of tricuspid incompetence ; on the other hand, I
have hitherto invariably failed to obtain it in other forms of cardiac
valvular disease, and in various cases of hepatic enlargement from
causes other than passive congestion. I can not but think that this
sign may furnish an important aid to diagnosis in cases where the
usual signs of tricuspid regurgitation are ill-developed or in abeyance,
and that it may prove a valuable factor in the difficult general problem
of prognosis in cases of cardiac disease."
THERAPEUTICAL NOTES.
Baths of Permanganate of Potassium are recommended by Hiill-
mann, of Halle ("Arch. f. Kinderheilk." ; "Dtsch. Med.-Ztg."), in the
treatment of scrofulous affections of the skin, eczema, and intertrigo,
and especially during the period of desquamation following measles,
scarlet fever, and chicken-pox. For a general bath, 15 grains of the
permanganate may be dissolved in a bucketful of water.
Pilocarpine in the Treatment of Stramonium Poisoning. — The
" Medical Times and Gazette " states that a Hungarian physician, hav-
ing been called to a child, four years old, in a comatose condition from
having eaten, as her playfellows said, two handfuls of the ripe berries
of the thorn apple {Datura stramonium), and in whose vomit the ber-
ries could be plainly detected, gave pilocarpine hypodermically, thinking
that, as that had proved successful in atropine poisoning, it ought to be
useful in datura poisoning also. He began with the fourteenth of a
grain, and, as no effect was produced, he increased the dose to a seventh.
As improvement was now evident, this was repeated. Altogether, in
five hours he gave six sevenths of a grain, and by that time the child
was convalescent. No physiological effects of pilocarpine were pro-
duced until the last dose was given, which was followed by profuse
secretion of saliva and perspiration.
The Hypodermic Use of Osmic Acid. — Schapiro (" St. Petersb. med.
Wchnschr."; "Med. Times and Gaz.") recommends the following solu-
tion:
Osmic acid 1 part ;
Glycerin 40 parts ;
Distilled water 60 "
He has injected this under the skin of the face without any un-
toward result.
Liquor Sodae Chloratae in the Treatment of Typhoid Fever. — Dr.
Pearson, of Cape Colony (" Lancet"), believes that the duration of every
case of typhoid fever may be shortened if it is taken in time. He
gives notes of three cases in which he produced good effects with La-
barraque's solution. To a lad fourteen years old he gave seven
minims and a half every three hours, and to a girl of the same age
tablespoonful doses of a mixture of a drachm and a half of the solution
and six ounces of water.
The Administration of Nitro-glycerin in Angina Pectoris. — Dr.
W. Murrell writes to the same journal, questioning the wisdom of the
admission of only one preparation of nitro-glycerin into the new British
Pharmacopoeia — that of chocolate tablets containing one one hundredth
of a grain each. Patients vary remarkably, he says, in their suscepti-
bility to this peculiar remedy. One man takes the six hundredth of a
grain, and suffers for hours afterward from intense headache, which in-
capacitates him for any kind of work ; while another patient will take
fifteen or twenty minims of the one-per-cent. solution ten or twelve
times a day, not only without inconvenience, but with the greatest pos-
sible benefit. " The small-dose man would find his time pretty fully
occupied if he had to divide each little tablet, weighing only two grains
and a half, into sis equal parts ; while his large-dose colleague might
experience some inconvenience in swallowing fifteen or twenty choco-
late drops at a dose, especially if he were suddenly arrested by an angi-
nal attack while crossing a busy thoroughfare." The alcoholic solution
is free from the objection implied, is cheaper, and admits readily of the
addition of adjuvants.
MISCELLANY.
THE MW YORK MEDICAL JOURNAL, October 17, 1885.
feet it res attfc ^ brb r jc s s je s .
RELIGION AND MEDICINE.
AN ADDRESS DELIVERED AT THE OPENING EXERCISES OF
THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF
THE CITY OF NEW YORK, SEPTEMBER 29, 1885,
By Professor WILLIAM MECKLENBURG POLK.
I would give much to have the custom abolished which
in our school demands each year an address from some
member of the faculty. If we were allowed to discourse on
a purely medical topic, one with which we should be famil-
iar, the wish would be less pressing ; but this we are for-
bidden by the unwritten law of this institution. Turn we
must, then, to some other field for a subject.
Medicine is commonly thought to be a very exclusive
pursuit, and yet, when we look about, it is a pleasure to
realize how we mingle with those of other pursuits — how
many are the points of contact between medicine and other
objects of intellectual ambition. In the direction of either
religion, law, or polite literature, we find fruitful fields ot
interesting inquiry ; and each is so broad as to furnish ma-
terial for a series of addresses. We will choose religion,
and endeavor hastily to point out some of the matters of
interest connected with its association with medicine.
From the very nature of its mission, medicine of neces-
sity was the offspring of religion. One of the grandest,
the most beneficent, unions between the two we find de-
picted in the records of the ancient civilization of Egypt.
From the enlightenment which marked the priesthood of
that country, they being in fact the center of the intel-
lectual growth of ancient Egypt, it was to be expected that
great results would accrue to medicine beneath their rule ;
and such was the case, for we find in their records evidences
of a medical and surgical proficiency but little, if any,
behind that of our middle ages. Three thousand years be-
fore the Christian era those men had formulated their pre-
cepts in a book which was to them a medical statute-book
of such influence that, if its teachings were followed im-
plicitly, the physician was held blameless, no matter what
the result to the patient. Such was the dignity of medi-
cine under these patrons, it wielded an important influence
in the state, and much of the light which in our day has
been thrown upon the life of that wonderful people comes
from the medical writing of that period. There is good
reason to believe that the temple of Serapis at Memphis
was the center of ancient Egyptian medicine. There re-
sided the fathers of the profession, the chief teachers,
and there no doubt flocked all those who were afflicted with
complex disorders, and no doubt it was there that the text
MSS. and monographs were prepared. If such was the
case, it was an admirable arrangement by which to sift the
prolific and loose writing which perhaps afflicted the prac-
titioner of that day. What a blessing some such institu-
tion would be to us! Could we have a central school to
which the compositions of our contemporaries could be re-
ferred in order that all which was a stale repetition of ac-
cepted ideas might be suppressed, and all which was a real
addition to facts might be recorded, what a saving of precious
time would be gained to us — time now wasted in the perusal
of old ideas in new dress which the ambitious but shallow
enthusiast of our day insists upon laying before us !
In some instructive and pleasing books the Egyptologist
Ebers, the scientific novelist, has spurred his imagination to
present us with charming pictures of this union of religion
and medicine, developing in one of his works the character
Nebeuchari, an oculist, whose fame spreading widely over
the East, was sought as the one to cure the blindness of
the mother of the Persian King Cambyses, a feat which he
accomplished by the operation of couching.
And yet it was through the work of this very king that
a final separation of medicine from religion was brought
about, for, as the conqueror of Egypt, he dealt its priest-
hood such a blow that, stripped of all prerogatives, they
never regained their ascendancy in the state. Medicine
after that was pursued as a separate profession. But truly
it was a noble beginning for our calling to be thus fostered
by religion as an ally in the most brilliant civilization of
the early ancients — for it was a civilization that was full of
wise and righteous conceptions ; one that marked the birth
of many other arts and sciences, which since have done so
much for the happiness of our own era ; one, too, that
stands second to no other in the noble and enduring edi-
fices with which it sought to manifest its devotion to its
gods, vast temples adorned with massive pillars, approached
through avenues of sphinxes and fronted by the obelisks
(those graceful shafts of solid stone) which, bearing aloft
their sacred inscriptions, were ornaments that imperial Rome
and even our own fair centers of Christian civilization were
but too eager to appropriate.
Turning to Buddhist India, that rival of ancient Egypt,
we find medicine in a position far from favorable. In the
hands of a special sect who were governed by oppressive
laws, it was driven into an inferior position. But this was
to be expected among a people whose religion was a grand
system for the cultivation of selfishness. With them the
end of life was " nonentity," the early attainment of which
was devoutly to be desired. For, if it were not granted, the
soul wandered from animal to animal, expiating in restless
transmigrations the imperfections of the earthly life.
The attainment of nonentity or, as it was called, " Nir-
wana," being then the object of life, the devout should seek
to destroy within himself all cleaving to existence, weaning
himself from every earthly object, and, by a life of isolation
— one given to self-denial, self-mortification — learn to sink
into perfect quietude — apathy. This was the preparation
for the end, a goal all the more rapidly reached as the
preparation was the more perfect. In the face of such a
religion, in the midst of the civilization that must spring
from such a faith, a class could have but little place whose
cardinal principle is that God has given man the earth and
the fullness thereof for his enjoyment; whose aim is to free
life from physical woe, to make it attractive by giving God's
image the health with which to cultivate in vigorous, joyous
strength the duties and obligations of this world ; to pro-
422
POLK: AN ADDRESS ON
RELIGION AND MEDICINE.
[N. Y. Med. Jodr.,
long his days, that he may enjoy the fruits of his labors and
correct the errors of bis youth.
Coincident with the decline of Egyptian civilization be-
gan the rise of the Greek, and in nearly all essential particu-
lars the one was based upon the other. This was distinctly
the case with all that pertained to medicine. For, as in
Egypt it began and was fostered as a part of the religious
system, so in Greece the temples of ^Esculapius were its
places of abode ; and as in Egypt the two were finally sepa-
rated, so was it here. But the manner of the separation
■was different.
In Egypt it followed the crushing blow dealt the priest-
hood by the Persians ; in Greece it resulted from the dawn-
ing of civilization upon the most active of the ancient minds
— a mind which, drawing most of its best inspiration from
Egypt, was quick to recognize that a time had come when
the union of religion and medicine was no longer beneficial
to either. The final blow to the dependence of medicine
upon the religious orders was given by Hippocrates when
he sought, though obscurely, to lay the foundation for its
study as an inductive science, when he endeavored to apply
to it the principle which about the same time Aristotle
outlined as the inductive system of philosophy.
As Greek culture and thought overcame all intelligence
to which they were opposed, so Greek medicine extended
itself wherever Greek civilization obtained a footing. Thus it
came about that, invigorated by that versatile people, medi-
cine returned to the land of its birth, as a department in the
Alexandrian Museum, and was in time to rescue from deca-
dence the remnants of the art which yet resisted the decline
which had fallen upon all purely Egyptian culture.
Unfortunately, it soon drifted from the anchorage which
Hippocrates endeavored to secure for it, and followed the
drift of the popular mind into the mazes of the speculative
philosophies which, during the whole of the later Grecian
and middle Roman periods, were the substitutes for religion
with the cultured. This, as will be seen, was pregnant with
dire results to medicine.
Such was the influence of one upon the other that we
find many of the early philosophers making a special study
of medicine or medical subjects as an aid to the develop-
ment of their various systems.
Aristotle, the father of scientific research, the friend of
Alexander, not only pursued it as an adjunct to his peculiar
work, but found in one of its subdivisions a substantial
means of support, for, after squandering an ample fortune,
he gained his livelihood as proprietor of an apothecary shop
at Athens.
It would be a pleasant task to follow medicine to the
museum at Alexandria, that brilliant creation of Alexan-
der's brother, and see what was attained under its direc-
tion, for surely much must have been accomplished under
a system which even at the dawn of Christianity had in-
vented the steam-engine. But our path leads in a different
direction.
Looking next at medicine under the Roman Empire, we
find it following the direction imparted by the Greeks, for,
while their political system fell before the arms of Rome,
their civilization remained triumphant and in turn overran
the whole of Rome's vast empire. It will suffice to say that
under the empire medicine in time received full recognition
both in its study and in its practice. Its teachers, being
provided for by the state, were associated with the teachers
of rhetoric and other departments of polite learning, and of
those who pursued it as a practice many held lucrative posi-
tions in the municipalities, and others attained high civil
rank.
We now reach the most interesting part of our question
— the relation of medicine to the Christian Church.
No one recognized the divine mission of our calling
more clearly than the fathers of the early Church, and they
were wise enough to avail themselves of it as one of the
means of extending the faith. The religious medical en-
thusiasts who, under the name of Perabolani, penetrated
most parts of the Roman Empire, in many places united
the functions of priest and physician, by which device they
gained freer access to the common people than would have
been possible in the guise of mere propagandists of a new
faith. While ministering to the body racked with pain, they
could the more readily bring the troubled spirit to dwell
upon the satisfying principles of the Christian faith, for the
attitude of the sick pagan of that day was much the same
as that of his ailing successor of to-day, the inclinations of
both being illustrated in the familiar lines,
" The devil was sick, the devil a saint would be ;
The devil was well, the devil a saint was he."
Apart from the aid thus derived from medicine as a
means through which to reach the lower orders of society,
there was much in common between the principles of a re-
ligion resting upon the divinely human precepts of the
" Sermon on the Mount " and those of a profession whose
purpose was the alleviation of human suffering.
Could those whose mission it was to guard, develop,
and extend these principles have harmonized their interests,
it would have been a happy day for medicine ; but the exi-
gencies of the occasion, the logic of events, drove them into
antagonism.
We have seen the intimate relation existing between
medical thought and culture and the pagan philosophies, an
association dating from the time of Aristotle and finding its
chief expression in the university at Alexandria, that center
of pagan thought in the Roman Empire, and the most pow-
erful opponent of the Christian faith.
This association had obtained for medicine not only full
recognition in the schools, but great prestige before the
people ; it was but natural, then, that it should be arrayed
on the side of paganism in the conflict which was waged
between the pagan and the Christian. We can not wonder,
then, that with the triumph of Christianity the intelligence
and culture of medicine were swept aside, that its institu-
tions of learning were suppressed, and that the regularly in-
ducted members of the profession were almost supplanted
by the Perabolani. It is true, however, that ample provision
was made for replacing the pagan hospitals by others more
in accord with the Church. Yet, noble as were these chan-
ties, they labored under an essential defect in having sub-
stituted for the educated, trained physicians, who had been
the directors of such institutions under the old order, un-
Oct, 17, 1885.]
POLK: AN ADDRESS ON RELIGION AND MEDICINE.
423
skillful, though- well-meaning and even enthusiastic ecclesi-
astics.
The consequences of this unfortunate and, for medicine,
disastrous antagonism were seen in the gradually increasing
credulity and imposture which in succeeding ages marked
the practice of our profession. For at length it came to
.pass that there was an almost universal reliance on miracu-
lous interventions, shrine and relic cures, as a means of
healing the sick and maimed.
This method of pursuing medicine as a practical art
reacted on its pursuit as a scientific study, checked its de-
velopment, and tended to its debasement. But the faithful
of that age have their representatives among us even now,
save that now they are to be found only among the igno-
rant.
And, after all, the mistake committed by the fathers was
that which all ages have witnessed — the blindness of man -to
the blessings God has already given him in the wonders of
this creation if he will only have the wisdom and patience
to put forth his mind and develop them.
While such was the fate of our science under the direc-
tion of the early ecclesiastics of the Christian Church, by
one of those seeming inconsistencies which Providence
sometimes displays in its workings, the Mohammedan faith
was being illuminated through the influence of medical
philosophy.
When first the children of the prophet overran the east-
ern and southern portions of the Roman Empire they
scorned all learning not contained in the limited pages of
the Koran. But through the influence of the Nestorians in
Asia, and the Hebrews in Spain and Africa, these fanatics
soon became enthusiastic admirers of learning. The man-
ner in which this was brought about is a great tribute to
the virility and universality of the principles of our pro-
fession.
The Mohammedan, the Hebrew, and the Nestorian
found the pivot of their faith to be the same. All believed
in the unity of God. But one of the party, however, ac-
cepted Mohammed as his prophet. Draper, in speaking
of this, says: " No doubt estrangement on this point might
have arisen, but a remarkable circumstance opened the way
for a complete understanding between them. Both the
Hebrews and the Nestorians had been among the most te-
nacious and successful devotees to the study of medicine,
and the Hebrews especially had long produced distin-
guished physicians. These studies formed a neutral ground
on which the three parties could unite in harmony, and so
thoroughly did the Arabians affiliate with these their teach-
ers that their physicians became their great philosophers,
their medical colleges their centers of learning."
Medical philosophy, thus finding shelter with the Mo-
hammedan and doing so much for their elevation and refine-
ment, widening thus its influence, was naturally viewed by
the Roman branch of the Church as even more offensive
than when allied to the ancient philosophies ; and when it
became evident that Hebrew physicians, as exponents of
Mohammedan civilization, were aiding in the development
of barbaric western Europe, it is not a matter of wonder that
that Church should have endeavored to degrade physicians
as a class, teaching the people to regard them as atheistical
disturbers of the divine order of things. And yet, while
this was the general attitude of churchly influence toward
medicine, some of the monastic orders were permitted to-
pursue its investigation ; but these, as a rule, so cloaked it
with the theories of the alchemist as to accomplish no more
than the keeping alive an ill-directed spirit of fantastic in-
quiry.
By the thirteenth and fourteenth centuries Arabian
medicine had made such inroads that the awakening spirit
of Christian civilization began to avail itself of its enlight-
enment, and then we find numerous instances of a liberal
patronage being extended to our profession by the great
men of the Church.
And yet the ancient attitude toward medical culture —
toward its pursuit as a department of science — had been
too firmly imbedded to be easily uprooted ; and even to
this day, in spite of the upheavals of the Reformation, a
remnant of that prejudice is witnessed in certain European
countries in the social status accorded to the members of
the profession.
But it is not disloyal in us to believe that, while the
early Church felt constrained to antagonize medicine as a
department of science, it was forced into the antagonism
that it might all the more securely lay broad the founda-
tions of that grand system of morals for the lack of which
Egyptian, Greek, Roman, and Mohammedan civilizations,
being weighed in the balance of human destiny, were found
wanting ; without which this glorious civilization of the
nineteenth century could never have been attained. And
in this era we can say that, in that she has given us this
wonderful age, with all of its possibilities and achievements,
she has fully compensated for every repression.
With that early Church the problems were indeed mo-
mentous, and the power with which she rose to the fulfill-
ment of her mission was such as to draw from one of her
keenest critics the following eloquent tribute :
" From her central seat at Rome her all-seeing eye, like
that of Providence itself, could equally take in a hemi-
sphere at a glance or examine the private life of an indi-
vidual. Her boundless influence enveloped kings in their
palaces, and relieved the beggar at the monastery gate. In
all Europe there was not a man too obscure, too insignifi-
cant, or too desolate for her. Surrounded by her solemni-
ties, every one received his name at her altar ; her bells
chimed at his marriage ; her knell tolled at his funeral.
She extorted from him the secrets of his life at her con-
fessional, and punished his faults by her penances.
" In his hour of sickness her servants sought him out,
teaching him by her exquisite litanies and prayers to place
his reliance on God, strengthening him for the trials of life
by the example of the holy and the just.
" Her prayers had an efficacy to give repose to the souls
of his dead. When even to his friends his lifeless body
had become an offense, in the name of God she received it
into her consecrated ground, and under her shadow he rested
until the great reckoning-day.
" From little better than a slave she raised his wife to be
his equal, and, forbidding to have more than one, met her
424
CURRIER: QONORRRCEA IN THE FEMALE.
[N. Y. Med. Jouk.,
recompense for those noble deeds in a firm friend at every
fireside.
"Discountenancing all impure love, she put round that
fireside the children of one mother, and made that mother
little less than sacred in their eyes.
" In ages of lawlessness and rapine among people but a
step above savages, she vindicated the inviolability of her
precincts against the hand of power, and made her temples
a refuge and sanctuary for the despairing and oppressed.
Truly she was the shadow of a great Rock in many a weary
land!"*
Original Communications.
GONOKKHCEA IN THE FEMALE.f
By ANDREW F. CURRIER, M. D.,
NEW YORK.
A paper with this title was published by me in the
"New York Medical Journal" for January 10 and 24, 1885,
in which the hope was expressed that the attention of the
profession in this country might be directed to this disease,
which was believed to be much more frequent in its occur-
rence and important in its bearings than was usually sup-
posed, even by well-informed members of the profession.
Various reasons have been given why this disease should
be practically ignored by the body of the profession, and
notably by the gynaecologists, within whose field its con-
sideration would naturally occur. The principal ones al-
leged are the difficulties in its diagnosis and the poor results
which attend its treatment. This is a humiliating confes-
sion when Sanger's statement is considered, that more than
one ninth of all gynaecological cases are now believed to be
of gonorrhceal origin. It seems additionally strange, also,
when one considers the great prevalence of gonorrhoea in
the male, and the attention which is devoted to its nature
and treatment.
I trust I may be pardoned if I draw somewhat upon the
paper to which I have referred ; perhaps also some points
in this paper, which may seem incomplete, will be found to
be treated with greater thoroughness in the former one.
The only claim which is made for this paper is that it is
mainly a resume, as faithful as possible, of the work which
has been done in the investigation of this disease. The
conclusions of the former paper, which subsequent experi-
ence and reflection have not induced me to modify, were :
1. Gonorrhoea in the female deserves more thorough in-
vestigation than it has yet received, especially in the light
of recently established facts.
2. The diagnosis of the disease, with improved methods
of investigation, chief among which are Situs's speculum
ami the microscope, is not so difficult as has hitherto been
considered, even in the absence of direct information of act-
ual exposure to gonorrhoeal infection.
3. There is a difference between the characteristic dis-
* John W. Draper.
f Read before the Medical Society of the County of New York, Sep-
tember 28, 1885.
charge of true gonorrhoea, both as to its nature and its ef-
fects, and other mucoid discharges from the female genital
tract. As a corollary to the foregoing statements, while in-
vestigators differ as to the significance of the micrococcus
of gonorrhoea, its constant presence in the discharges is not
denied.
4. Gonorrhoea in the female is identical with gonorrhoea
in the male; the fact of individual peculiarities and suscep-
tibilities is not questioned.
5. A series of careful investigations in well-defined
cases, in a hospital or other place in which the changes and
developments can be accurately noted, is desirable. No line
of treatment can be recommended as unfailing and entirely
satisfactory until the results of such investigations are
known.
No important contribution to this subject has been made
in American literature, in so far as I can ascertain, with
the exception of Dr. Noeggerath's notable paper, which was
read before the American Gynaecological Society in 1876,
having been previously published at Bonn, in the German
language, in 1872. It is but just to say that Dr. Noegge-
rath's views inaugurated an epoch in the history of this dis-
ease. They were received with great incredulity by the
profession here and abroad. Their suggestivencss has borne
fruit, however, in the experiments and observations of a
number of careful workers, and some of those who were
most outspoken in their disagreement with those views now
give a more or less positive assent to them. Martineau and
a few other French writers have recently described certain
rare forms of the disease, but the most important recent
contributions have been made within the past year in Ger-
many by Bumm, Sanger, and Oppenheimer.
I. — In regard to the aetiology of the disease, while the
evidence is not absolutely complete, even those who are
skeptical will admit that the probabilities are altogether in
favor of a parasitic origin. Such an origin was maintained by
Neisser in 1879, after an elaborate series of investigations.
Neisser was not the first, however, to assert such an origin,
since Donne, in 1844, discovered a spore in urethral dis-
charges which he named Trichomonas vaginalis.
Salisbury, in 1868, discovered Crypta gonorrhoica ; Jous-
seaunie, in 1872, discovered Algue genitale, and Hallier in
the same year (1872) Konotecium gonorrhoicum. All these
were forerunners of Neisser's gonococcus, but the latter
was presented to the public at a time when the germ
theory had captivated the minds of all men, and was there-
fore received with much more favor and sympathy than its
predecessors. Bumm asserts (" Arch. f. Gyn.," xxiii, 3), as
the result of extensive experiment, not only that the con-
tagious property of this disease is located in the gonococcus,
but that this microbe is distinguished from all others which
are contained in the discharges from the genital tract by its
faculty of penetrating living tissues and its manner of mul-
tiplication. Widmark has also shown (" Svenska lakares-
iillsk. Forb.," S. 159, 199, and "Jahrb. f. Kinderh.," xxiii,
1 and 2, p. 209) that in gonorrhoeal conjunctivitis in adults
the gonococci show the same tendency to penetrate below
the epithelium of the cornea and into the lymphoid tissue
which Bumm has observed in the tissues of the genital
Oct. 17, 1885.]
CURRIER: GONORRHOEA IN THE FEMALE.
425
tract. In the cornea of the new-born infant, on the other
hand, the lymphoid tissue is absent, and the gonococci are
found upon the epithelium. The form and size of the
gonococcus are stated by Bumra to be differential charac-
ters which are of minor importance, and these statements
must be borne clearly in mind in examining the opinions of
those who do not agree with Neisser and his followers as to
the infective character of the gonococcus. The identity of
this disease with the ophthalmo-blennorrhoea of new-born
infants has been shown by Sattler, Haab, and other compe-
tent ophthalmologists, the distinction between it and ordi-
nary purulent catarrh of the eyes in new-born infants con-
sisting in the absence of gonococci in the latter and their
constant presence in the former, from inoculation with
gonorrhoeal virus. (See Haab, " Rev. gen. d'ophthal.,"
June 30, 1885, p. 265.)
Of gynaecological investigators in this field, Kroner
stated that, of ninety-two cases of ophthalmo-blennorrhcea
neonatorum which he had seen, the gonococcus was found
in sixty-three. (See " Am. Jour, of Obst.," February, 1885,
p. 197.) He also examined the vaginal secretions of twenty-
one mothers in the eyes of whose infants gonococci had
been found, and of eighteen mothers in the eyes of whose
infants no gonococci had been found. In the former group
gonococci were found in all cases, and usually without the
presence of any other bacteria.' In the latter the character-
istic hives of gonococci were absent, though diplococci were
fftund. Nothing satisfactory could be obtained from the
mothers in these cases respecting gonorrhoeal infection, and
the presence or absence of gonococci was taken as sufficient
evidence for the basis of a diagnosis. Oppenheimer exam-
ined the secretions from the upper portion of the vagina
which were taken from one hundred and eight pregnant
women at the Heidelberg Obstetric Clinic, between January
and September, 1883, and found gonococci in thirty of them
(Untersuchungen iiber den Gonococcus, " Arch. f. Gyn.,"
xxv, 1, p. 51).
He also made some investigations upon the subject of
ophthalmo-blennorrhoea neonatorum, and found that it usually
occurred within five days from birth, or about the usual in-
cubation period of gonorrhoea, and that it was most fre-
quent in those cases in which parturition had been tedious,
notably in so-called dry bh-ths.
In cases in which blennorrhcea or corneal ulceration was
present at birth, the supposition was advanced that the bac-
teria might have penetrated the foetal envelopes and in-
fected the foetus in utero. As evidence of another character,
Zweifel had the hardihood to inoculate the eyes of healthy
infants with lochial secretions in which no gonococci could
be found ; no blennorrhcea resulted (" Arch. f. Gyn.," xxiii,
1883). Kroner also inoculated the conjunctivae of five blind
persons with secretions from the vagina of a pregnant wo-
man in which no gonococci were found, no bad results fol-
lowing. In the case of another blind person the eyes were
inoculated with muco-purulent matter from the vagina of a
mother whose infant was suffering from simple purulent
conjunctivitis, likewise with a negative result (" Am. Jour,
of Obst.," February, 1885, p. 197). Important testimony
as to the infective character of the gonococcus also resulted
from some recent experiments of Welander (" Gaz. med.
de Paris," June 7, 1884, p. 267).
This investigator found gonococci in the purulent ure-
thral secretions of seventy-nine women. In twenty-five of
them he traced the source of the contagion, and discovered
gonococci in the urethral discharges of each of the twenty-
five men. Vaginal secretions which contained no gonococci
gave negative results when used for inoculation purposes.
This experiment was tried in three cases. In one the secre-
tion was taken from the vagina of a woman who was men-
struating at the time of the experiment. From the urethra
of the same woman matter containing gonococci was also re-,
moved and applied to the healthy urethra of a man. At the
end of two days this man began to suffer with an urethral dis-
charge, in which cocci were discoverable upon the epithelial
cells. On the following day there was a characteristic gonor-
rhoeal discharge which contained an abundance of gonococci.
Similar results followed inoculation with matter from the in-
fective urethral discharges of the two other women.
Koch demands the satisfaction of three conditions in
proving that a given infectious disease is caused by a given
micro-organism :
1. That one and the same form of spore be always found
in a given disease.
2. That the same be easily recognized, morphologically
or by its chemical relations, as well as by its behavior to
coloring materials.
3. That the disease may be artificially produced in a
healthy individual by inoculation with pure cultivations of
spores.
These requirements, says Oppenheimer (" Arch. f. Gyn.,"
xxv, 1, p. 51), are all fulfilled by Neisser's gonococcus in its
relations to gonorrhoea. Pure cultivations have been ob-
tained to the fourteenth generation, and, although the dis-
ease could not be induced (Oppenheimer, loc. cit.) in dogs,
cats, puppies, and mice, it has been in the human subject
by Bokai, Bockhardt, and Welander.*
Further testimony as to the infectious nature of the
gonococcus is at hand, if it were required, from a number
of observers who have treated the question experimentally.
(See Leistikow, " Charite Annalen," 1882; Koningstein,
"Arch. f. Kinderh.," 1882; Arning, " Vierteljahresschrift
fur Dermatologie," 1883; O. Haab, "Festschrift fur Hor-
ner," 1880.) Among those who are still skeptical or incredu-
lous with regard to the pathogenic powers of the gonococ-
cus, mention may again be made (as in my former paper) of
Sternberg. He maintains that the o-onococcus is not mor-
phologically distinct from all other bacteria (" Med. News,"
Philadelphia, xlv, 1884, p. 426), an identical one being
found in normal human saliva, in pustules resulting from
contact with the cadaver, and in the pus from acute ab-
scesses ; but he very properly adds that it is not essential for
the gonococcus to have distinguishing morphological charac-
teristics to establish its position as the cause of the infective
virulence of gonorrhoeal pus. This is simply in accord with
what has already been quoted from Bumm's statements, and
* Stub reports that the gonococcus will produce a condition which
closely resembles gonorrhoea, in all its details, in dogs and rabbits.
" N. Y. Med. Jour.," May 23, 1885.
426
MINOT: THE EARLY STAGES OF HUMAN DEVELOPMENT. [N. Y. Med. Jour.,
is also in line with Koch's cholera investigations, at least
three bacilli having been discovered which present morpho-
logical peculiarities resembling those of the comma bacillus.
In following these investigations, Sternberg and two other
gentlemen applied to their own urethra?, August 23, 1884,
cultivations of gonococci of the ninth generation, taking all
necessary precautions that the microbes should not be dis-
turbed. The results were negative, and these, with other
similar unsuccessful experiments, tended to establish Stern-
berg's skepticism as to the infective properties of the gono-
coccus. He declares, however, with perfect frankness, that,
notwithstanding his own failures, the experiments of Bock-
hardt and Welander, which I have quoted (See "Nord.
med. Ark.," Stockholm, 1884, xvi, No. 2), together with evi-
dence relating to other infectious diseases, warrant belief in
the possibility that virulence does depend upon the presence
of this micrococcus, which is a widely-distributed and usual-
ly harmless organism, but which may acquire specific patho-
genic power, as a result of special conditions relating to its
environment, which pathogenic power may be lost, he
thinks, when these conditions are removed. This line of
reasoning on the part of an expert and conscientious inves-
tigator seems, to my mind, a virtual admission of the special
infective power of the gonococcus, especially when we bear
in mind that there is no more inconstant quantity than the
physical condition and susceptibilities of a given tissue of
the body. Therefore the negative results of inoculation
with the gonococcus, in any number of cases, need not out-
weigh positive testimony in a single case, if all the condi-
tions are reliable. The immunity from contagious diseases
in general which seems to be peculiar to some individuals
is certainly no argument against the general theory of sus-
ceptibility to such diseases.
De Amicis professes ("France med.," Paris, 1884, ii, p.
1095) to have produced blennorrhagia with injections of am-
monia, and to have found micrococci and diplococci on the
sixth day which he could not differentiate from those which
were obtained in cases of urethritis with a clear history of
contagion. He affirms that diplococci are to be differenti-
ated from micrococci which are found apart from the geni-
tal passages only by their size, distribution, and mode of
grouping. Bumm and Widmark have been quoted as in-
sisting upon a more important distinction than this, namely,
the property of penetrating living tissues. Neither De
Amicis nor Sternberg has made any comment upon this
characteristic. De Amicis agrees with Sternberg that the
gonococcus may possibly have pathogenic properties under
certain conditions, in which the mucous secretions act as
cultivation -fluids. At such times the microbes develop
with great activity, and may then possess an exceptional
though not an original infective power. In legal medicine
it was thought that the presence of gonococci could not be
taken as a necessary evidence of venereal disease of inflam-
matory origin. Welander, whose important experiments
have been quoted, concludes that there is a practical impor-
tance in the presence of these organisms, especially as a
means of deciding upon the existence of infectiousness in
prostitutes and others, which would certainly give them a
value in a medico-legal sense.
Thus we have the arguments pro and con with regard to
the infectious character of the gonococcus, and it appears
that no one who has experimentally investigated the subject
and whose work is accessible to the public ventures to give
more than a modified dissent to the statements which were
made by Neisser. That the microbe, at least in so far as
morphological peculiarities are concerned, is not limited to
the genital organs, or even to the eyes, is probable. Neither
must it be overlooked that von Tischendorf professes to have
found gonococci in the vaginal discharges of little girls suf-
fering from scarlet fever, in which an origin by sexual con-
tact was excluded, and in which, also, inoculation produced
similar conditions in other children (" Am. Jour, of Obst.,"
Feb., 1885, p. 199), but, in this case also, there is no indi-
cation that the distinctive characteristic which was men-
tioned by Bumm was present. Little remains to be said
regarding the aetiology of the disease. A history of recent
impure sexual contact, in the presence of certain well-known
clinical features, with or without an examination for gono-
cocci with the microscope, will usually be accepted as suffi-
cient evidence of gonorrhoea. The search for these mi-
crobes is always difficult, and often unavailing when only a
few are present. That we are to depend mainly upon the
clinical features for a diagnosis is agreed by Sanger, Frank-
el, Kroner, and Noeggerath. This is especially true in
many of the cases of latent gonorrhoea concerning which
the skepticism of earlier days is passing away. The con-
version of Fritsch, who was once one of the most pro-
nounced opponents of Noeggerath's views, is an evidence of
this.
(7b be concluded.)
THE EAELY STAGES OF HUMAN
DEVELOPMENT.
By CHARLES SEDGWICK MINOT, M. D.,
BOSTON.
(Concluded from page 401.)
The second specimen to be considered now is His's em-
bryo L (1, Heft i, 135-139), which measured 2*4 mm. in
length, and was obtained from a chorionic vesicle of 8 to-
9 mm. diameter. The specimen had been considerably in-
jured, and no exact knowledge could be obtained in regard
to the heart or the disposition of the allantois or the am-
nion. Precisely these three points are elucidated by Coste,
while His has worked out the internal anatomy of his speci-
men ; in short, the two descriptions complement one an-
other in a remarkable manner.
Nearly all that His ascertained is represented in the
accompanying illustrations, Fig. 7. A gives a side view
showing the thickening of the head end and the upward
curving of the tail, and the two gill-slits in the cervical
region ; the mouth, M, is very large ; between it and the
first gill slit intervenes the thick ridge, Mx, of the first gill-
arch (branchial or visceral arch, auct.), which becomes the
mandible; between the two slits is the second or hyoidean
arch, in connection with which the hyoid bone afterward
arises. A large body-cavity is present, C, Coe ; the walls of
the body (somatopleures) pass over along an extended line
into the amnion ; the connection between the embryo and
Oct. 17, 1885.] MINOT: THE EARLY STAGES OF HUMAN DEVELOPMENT.
427
the yolk-sack is already very much re-
stricted compared with Coste's embryo,
Fig. 4 ; at the side of the head a line
and shadow mark the position of the
optic vesicle. B is a ventral view; it
shows the large, wide month, M, which,
according to His, was apparently in
communication with the intestinal ca-
nal, which is nothing but a straight
tube with a great pharyngeal dilatation
and a wide, open union with the yolk-
sac ; the median light band shown at
the back of the mouth is the central
nervous system shining through the
covering tissue. C is intended to show
the digestive tract, and is partly a hori-
zontal section. Especially to be noticed
is the enormous size of the pharynx
(the region of the branchial arches),
the straight, short intestine, and on
each side of the latter the distinct
body-cavity, Coe ; there are indica-
tions of four visceral arches, Mx, 2, 3, and If. ; in front of
the pharynx is shown the ventral surface of the fore-brain
or first cerebral vesicle, with its lateral diverticula, the optic
vesicles. D is a dorsal view of the brain and medullary
canal, which is still open at a. The brain and spinal cord
are already differentiated by the dilatation of the former.
The brain subdivides very early in all vertebrate embryos
into three dilatations or primary vesicles; but in this em-
bryo the two anterior dilatations are not yet clearly sepa-
rated from one another, hence there is only one widening
of the brain in front ; the front end is seen to bend down-
ward and give off the conspicuous optic vesicles, Op, which
therefore arise before there is any trace of the cerebral
hemispheres — an important fact ; the posterior and larger
dilatation is the primitive medulla oblongata ; no trace of
the cerebellum has appeared. The whole nervous system is
a tube the walls of which are of nearly uniform thickness,
except that the dorsal wall of the third vesicle (the cavity
of which becomes the fourth ventricle of the adult) is very
thin. This thin wall is persistent in the adult and never
develops into nervous substance. On each side of the
medulla lies a round cyst, the auditory sack, Au, the begin-
ning of the adult membranous labyrinth. Three other
points not shown in the figures remain to be noticed. 1. In
the tissue at the back of each body-cavity, Coe, was found a
single longitudinal epithelial canal, the Wolffian duct, the
first part of the uro-genital apparatus to be developed. 2.
Close below the nervous system lay a median rod of cells
with a small central cavity ; this rod is the notochord or
chorda dorsalis, the primitive embryonic axis around which
the vertebrae are formed later. 3. All the tissues are still
embryonic — that is, the cells are not yet differentiated into
tissues. Unfortunately, the number and disposition of the
myotomes were not ascertained.
It will be as well to mention here, rather than later, four
descriptions of young embryos, which either belong in this
stage or are a little older. Of these descriptions Remy's
Fig. 7.— His's Embryo L ; 2'4 mm. long. A, side view ; B, ventral view ; C, ventral view with the walls
of the body and intestine seen in frontal section ; D, dorsal view, showing the central nervous system.
M, mouth ; Mx, inferior maxilla or mandible ; 2, hyoid arch ; Vd, vorderdarm ; V, splanchnopleure of
the yolk-sack ; 2, 3, and 4, gill-arches ; Cm, coelom or primitive body-cavity ; Op, optic vesicle ; Au, audi-
tory vesicle (otocyst) ; a, point where the medullary groove has not yet closed.
alone brings much of any positive information, but the size
and age of his embryo can only be guessed at.
The first of the embryos is Schroder van der Kolk's
(5, p. 106 ff., with figures on PI. ii). Kolk's figures are not
very clear. He states that his specimen had two gill-clefts
and measured 1*8 mm. in length ; one can not but ask, Was
it not really larger % Kolk's figure suggests that the speci-
men was doubled up ; if this was the case, the embryo, when
straightened out, would agree fairly well with His's embryo
L, above described. Professor His, for reasons not clear to
me, considers Kolk's specimen as somewhat older, but to
this opinion I am unwilling to accede.
The second embryo is that of Hennig, whose descrip-
tion (6) leaves very much, and whose figures leave every-
thing, to be desired. From this paper we can gather very
little, except confirmation of Coste's statements in regard to
(1) the disposition of the amnion and its connection with
the stalk of the allantois ; (2) the absence of a yolk-stalk.
Schwabe's (7) embryo, to which reference has already
been made and which he assumes to be thirteen to fifteen
days old, was probably sixteen to twenty days old, as shown
both by his own data and by the description of the ovum.
Very likely it was a little younger than Coste's embryo (v.
sup.). There were a well-developed yolk-sac and an amnion
closely investing the embryo, which was connected with the
chorion by a short allantoic stem. The chorionic villi were
considerably branched and entirely filled with mesoderm ;
their tips had little thickenings of the epithelium by which
they were attached to the decidua ; this was the only con-
nection between the foetal and maternal tissues. This last
fact is an interesting confirmation of the observations of
Ahlfeld and Langhaus.
Remy's embryo (8) was also a young one, but its exact
age is not stated, nor are the measures of its length given,
except in the title, where it is called " long d'un centimetre."
From the stage of development, and from the statement in
the text that the chorionic cavity measured 20 x 10 mm.,
428
HINOT: THE EARLY STAGES OF HUMAN DEVELOPMENT. [N. Y. Med. Jock.,
it seems impossible that the embryo was so large ; we
should rather expect an embryo of 3 mm. Remy's figure
is too inexact for one to make out the form of the embryo.
If he gives the length correctly, the specimen must have
been about a mouth old. As to its structure, Remy gives
the following details: The medullary canal was still united
with the ectoderm at its lower end, and extensively so over
the fourth ventricle, which was entirely closed. The heart
already had muscular stria?. The epidermis had two layers
of cells, the outer somewhat flattened, the inner cuboidal.
The cutis was not differentiated. The epithelium of the
chorion he describes as maternal — a common error. He also
distinguished the inner membrane of the chorion, the allan-
toic. He has also seen, apparently, what is known as Lang-
haus's cellular layer, but has taken it for a deep portion of
the epithelium, which he accordingly calls many-layered.
The cellular layer is a special stratum which arises between
the connective tissue and the epithelium of the chorion ; its
orio-in is not definitely known. I am unwilling to hazard
an opinion as to where Remy's embryo really belongs.
Summary. — During the fifth stage the head of the em-
bryo acquires great prominence by the growth of the heart
and the development of the branchial area. The chorion,
of course, has enlarged, but we can not at present give its
diameter exactly; normally it may be about 10 mm. The
chorionic villi are constricted at the base and more or less
branched; apparently they may either be hollow or may
already contain a core of connective tissue. The allantois
is still short and thick ; the amnion is very much as in the
previous stage, but of course somewhat expanded ; the yolk-
sac appears more like an appendage to the embryo. The
embryo has enlarged, especially in front ; its normal length
we may assume to be about 2'6 mm., but this is very
open to correction; the back is nearly straight; the thick
caudal extremity curves upward ; the heart and aortic arches
develop rapidly, and accordingly is the region between the
head and the anterior margin of the yolk-sac extended.
The heart itself is still tubular, but makes a great bend to
the right; the posterior end of the tube receives the veins,
the anterior end forms a little enlargement, the commencing
bulbus aprtce, and then gives rise to the aortic arches. Be-
tween the arches appear the gill-clefts at the side, and since
there are five arches there are four gill-clefts. The pharynx,
or region into which the gill-clefts open, is enormously di-
lated. The rest of the digestive tract is a simple tube com-
municating with the hollow yolk-sac. The Wolffian duct
is present, but no other part of the uro-genital system. The
notochord is tubular. The medullary canal closes through-
out its whole length during this stage ; it separates into
brain and spinal cord ; the brain consists of two dilatations,
of which the anterior corresponds to both fore- and mid-
brain, and gives off the long-stalked optic vesicles ; the pos-
terior dilatation is the hind-brain. The auditory organs
exist as a pair of round otocysts.
6. EMBRYOS OF THE SIXTH STAGE. FORMATION OF THE HEAD
BEND AND OF THE WOLFFIAN BODIES.
From this stage onward the embryo becomes more and
more bent, the back becoming so convex that at one period
the head and tail of the embryo almost touch. It thus be-
comes quite impracticable to measure the longitudinal axis,
so we have to adapt ourselves to the circumstance and give
as a measure for comparison the greatest length in a straight
line of an embryo in its natural attitude. Formerly investi-
gators usually attempted to give the actual length ; conse-
quently many of the older published measurements appear
excessive in comparison with those now given ; evidently
this discrepancy is often only apparent.
The length of an embryo should always be given as ob-
tained by measuring the greatest longitudinal diameter of
the body, including the head; the limbs ought not to be in-
cluded, because in the earlier stages, being at right angles
to the body, they can not be included, and therefore ought
to be excluded in the later stages in order to keep the meas-
urements strictly comparable.
In the sixth stage (His's eighth) wre find five aortic
arches, the head bent down, the back convex, and the heart
very asymmetrical. Our accurate knowledge of this stage
in man we owe to His (Embryos M and BB). Besides
these two, Professor His has also referred the following em-
bryos described by other authors to this stage:
1. Allen Thomson's ovum, iii (2).
2. C. E. von Baer's, described in his " Entwickelungs-
geschichte," Bd. ii, Taf. vi, Figs. 15, 16; also in von Sie-
bold's "Journal fur Geburtshulfe," 1834, xiv, 409.
3. Schroeder van der Kolk's (5).
4. Alexander Ecker's (9).
5. Professor Hecker's {vide infra).
6. Beigel's (vide infra).
7. Bruch's (10).
Of these, Thomson's embryo, the figure of which, reduced
in scale, may be found in His (1, Heft ii, Fig. 18, marked
AT 3 in the group of figures on p. 32), is the only one de-
serving much attention. Thomson's embryo resembles His's
M (see below) quite closely, not only in general form, but
also in the possession of two distinct gill-clefts and the
great prominence of the heart. Its length is given by
Thomson at \ inch — about 3 mm. Von Baer's embryo, on
the contrary, was only 2 mm. long ; it was surrounded by
an amnion of about 4'5 mm. in diameter, which is abnor-
mally large ; von Baer observed four open gill-slits ; the
hind end of the body was partially atrophied, which ac-
counts for the short length. Van der Kolk's embryo, as I
have already stated, I refer not to this but to the previous
stage — perhaps mistakenly, but I think not. In Ecker's
ovum the chorion measured 12 by 9 mm., and the embryo
only 2 mm. ; the author's description is very meager and his
figures are not distinct. Ecker expressly compares it with
an ovum of Wagner's, figured in Wagner's " Icones Physi-
ologicse," and again in Ecker's " Icones Physiologicae," Taf.
xxv, Fig. 5 ; but the comparison apparently refers only to
the chorion, for Wagner's embryo was evidently older, be-
ing 4-5 mm. long and having external traces of limbs. Heck-
er's ovum (1) I know only through Professor His's refer-
ence, which leaves the impression that Becker's description
is so unsatisfactory as to render it a matter of surmise ex-
actly what stage of development the specimen had reached_
In regard to Beigel's ovum (in the previous article I ex-
Oct. 17, 1885.]
MINOT: THE EARLY STAGES OF HUMAN DEVELOPMENT.
429
pressed my opinion that it is a much older and abnormal
embryo) I do not differ with Professor His as to the slight
value attaching to Beigel's description. Bruch's embryo (10,
Bd. vi, Taf. x [40]) appears to me, from his description and
plate, to have been very abnormal.
Of these seven embryos, Van der Kolk's and Beigel's do
not belong to this stage ; von Baer's and Bruch's were ab-
normal ; Hecker's is questionable ; Ecker's is somewhat un-
certain ; and Thomson's is the only satisfactory one. Of
Thomson's only the general appearance is described, but
that confirms what we learn from Ilis's two embryos, M (1,
Heft i, 116-134) and BB (1, Heft ii, p. 90, and " Arch. f.
Anat. u. Physiol.," anat. Abth., 1881, pp. 310, 311). The
latter embryo has also been catalogued by His with No. lxv.
M appears to be somewhat the younger, but no data as
to its age are preserved ; the embryo was 2-6 mm. long, its
chorion 7-5x8 mm. in diameter. The embryo BB was
3*2 mm. long; its chorion 11 x 14 mm. in diameter; its
age, from the data given by His, I think was probably twen-
ty to twenty-one days. The following description refers to
M only, as the full account of BB is not yet published :
The head is bent down, the back is very convex, and the
caudal extremity is rolled up and turned toward the right,
while the head is twisted slightly toward the left ; the long
axis of the body therefore describes a large segment of a
spiral revolution ; the spiral form is more marked in em-
bryos a little older ; it is, of course, produced by the more
rapid growth of one side ; in view of the differences be-
tween right and left in the adult, it is very interesting to
find differences between symmetrical parts showing so very
early in the heart of the embryo and the twisting of the
body. The caudal end of the body has grown very much ;
the allantois-stalk has presumably lengthened; the neck of
the yolk-sac is much constricted; four gill-arches can be
distinguished externally ; the otocyst, Fig. 9, Ot, has be-
come somewhat pear-shaped. The neural canal is com.
pletely closed, the mid-brain and fore-brain have become
perfectly distinct, and the latter has begun to form the
hemispheres in front. The mouth is large, and at its upper
corner the protuberance of the maxillary process is marked ;
the mandibular process is very prominent.
Fig. 8, a geometrical reconstruction from the sections,
shows the anatomy of the entodermic canal. The pharynx,
bounded on each side by five branchial arches, is still very
large and tapers down posteriorly ; the intestine is turned
to the left and opens into the broad canal, V, of the yolk-
sac ; just in front of the yolk-sac there is a small ventral
diverticulum, Li, probably the commencement of the liver;
behind the yolk-sac the cylindrical intestine runs over into
the tail, where it expands into the cloaca and gives off a
cylindrical canal, which has very thick connective-tissue
walls, and is the allantois-stalk, All. This is the youngest
allantois of which the structure is known ; therefore we add
at once that the walls carry two large allantoic arteries,
Fig. 9. The body-cavity, Fig. 8, Coe, has at its back on
each side a longitudinal ridge, the commencement of the
Wolffian body; the ridge already contains traces of the
canals of the Wolffian body.
Of special interest is the arrangement of the circulatory
apparatus, Fig. 9, since this is the youngest human embryo
of which the vascular system has been elucidated. To
Fig. 8.— His's Embryo M ; anatomy of the entodermic canal. N, N, central
nervous system ; 1, 2, 3, 4, and 5, gill-arches ; Lu, liver ; Cos, body-cavity ;
All, allantois ; V, stalk of yolk-sac.
avoid confusion, it must be stated that the whole of the
aortic portion of the heart up to the origin of the aortic
Fig. 9. — W. His's Embryo M. Op, optic vesicle ; A, aorta ; O/n, omphalo-
mesaraic vein; Au, arterise ombilicalee ; All, allantois; Cars, cardinal
veins ; Vh, right umbilical vein ; Ao, dorsal aorta ; Jg, jugular vein ; ot,
otocyst.
arches is double-walled, there being a very considerable
space between the endothelial tube and the main mesoder-
mic wall. In the figure the arteries are shaded dark. The
heart is an S-shapcd tube ; the venous end is convex toward
the head, the arterial end convex toward the tail ; when
viewed from in front, the venous portion is seen on the left,
the arterial portion on the right of the embryo. The heart
is continued forward by the large aorta, A, which gives off
five branches on each side of the neck; these branches
unite again on the dorsal side and run backward, to unite
with the fellow-stem and so form the single median dorsal
430
MINOT: THE EARLY STAGES OF TIUMAN DEVELOPMENT. [N. Y. Med. Jour.,
aorta, Ao, which runs way back and terminates in two large
brandies, An, which, curving round, pass out through the
allantois-stalk. The five brandies in the neck are known as
the aortic arches, and the column of tissue around each
branch constitutes a so-called branchial or visceral arch ; be-
tween the five arches are four spaces, in each of which a
gill-cleft is ultimately formed. The veins are: 1. The
jugular, Jg, and cardinal, Car, which unite and form a
single transverse stem, the ductus Cuvieri ; the cardinal
veins receive chiefly the blood from the Wolffian bodies,
and atrophy later with the bodies. 2. The large umbilical
veins which pass up, Vh, from the allantois and also open
into the ducti Cuvieri, but nearer the heart than the jugulars
and cardinals. 3. The omphalo-mesaraic veins, Om, which
come up from the yolk-sac.
His describes for both embryos the disposition of the
pericardial cavity and the septum dividing it from the
body-cavity with great minuteness, in order to elucidate
the development of the diaphragm. But this problem is so
obscure and complex that it is best not to touch upon it
here.
Summary. — During the sixth stage the most striking
changes are the curling up of the embryo, the closeness of
the amnion to the embryo, the contraction of the neck of
the yolk-sac, the growth of the caudal extremity, the as-
sumption of the pear-shape by the otocyst ; internally, by
far the most important advance is the appearance of the
Wolffian bodies.
The embryo is from 2*6 to 3*2 mm. long and about
three weeks (twenty-one days) old ; the chorion is from
(say) 8 to 13 mm. in diameter. Besides the prints noted
above, we may mention for this stage the separation of mid-
and fore-brain, the commencement of the hemispheres, the
progress of the vascular system, especially in the heart,
which has distinct auricles and ventricles, also the bending
of the intestinal canal into an unsymraetrical position.
APPENDIX.
1. Contents of the Chorionic Vesicle. — In early stages, as
we have seen, there is a large chorionic cavity, which in
later stages is obliterated by the expansion of the amnion.
The space between the chorion on the one hand and the
amnion and the yolk-sac on the other is filled with a fluid
which is coagulated by the action of hardening agents, mak-
ing a network of threads. This observation, which has
been often verified, is all that we know concerning the na-
ture of the chorionic fluid ; it is probably of a serous char-
acter, and may very likely be found to contain free connec-
tive-tissue cells (wandering cells or leucocytes).
2. Structure of the Yolk- Sac. — The histology of the
yolk-sac has never been properly studied. In regard to its
structure in earlier stages I can find no observations. Kol-
liker (" Grundriss," 162) states that in the fourth or fifth
month it is from 7 to 11 mm. in diameter and hollow, with
an external envelope of connective tissue and an internal
pavement epithelium of fatty cells. The inner surface has
small vascular villi, rudimentary remains of structures said
to be well developed in some of the lower vertebrates.
In regard to the contents of the yolk-sac, von Baer |
states (12, ii, 272) that in very young ova (six to seven
weeks) the contents are sometimes as thick and yellow as
the yolk of a bird's egg; in ova of this period the thinner
the contents the more rounded and fully distended is the
yolk-sac. A little later the contents are always fluid, but
at the end of pregnancy, according to B. S. Schultze (11),
when the sac has shrunk to 4 to 7 mm. in diameter, it
contains variable quantities of fatty substances and carbo-
nates. It thus appears that during the first month at least
the yolk-sac does contain more or less true yolk — an idea
which is confirmed by Rauber's observations on the rabbit's
ovum. It seems, indeed, probable that the rudimentary
yolk-sac of man still performs for a short period the func- -
tion of a food reservoir for the embryo.
LITERATURE.
1. His, Wilhelm (1880, 8vo, mit Atlas, fob). Anato-
mie menschlicher Embryonen.
Heft i, 1880 (1882). Embryonen des ersten Monats,
p. 184, mit Atlas von 7 Tafeln.
Heft ii, 1882. Gestalt und Grossenentwickelung bis
zum Schluss des 2. Monats. Pp. 104. Leipzig (F. C. W.
Vogel).
2. Thomson, Allen (1839). Contributions to the His-
tory of the Structure of the Human Ovum and Embryo be-
fore the Third Week after Conception, with a Description
of some early Ova. (Further notes on these ova are given
by His, 1, Heft ii, pp. 34-36.) " Edinburgh Med. and Surg.
Journal," Hi, 110-136, PL ii.
3. Krause, Wilhelm. " Arch. f. Anat. u. Physiol.,"
1875, 215. Criticised by His (i, p. 72) and Kolliker, " Ent-
wickelungsgeschichte," 1879, pp. 306 and 1013. Krause's
reply, " Zeitschr. f. wiss. Zool.," xxv, 131. Criticised also by
Ahlfeld, "Centralbl. f. Gynakol.," 1880, No. 25; Krause's
reply, Ibid., 1881, No. 1. See also Ecker's criticism in His's
"Arch. f. Anat.," 1880, 405.
4. Coste, Jean Jacques, M. C. V. (1847-1859). His-
toire generale et particuliere du developpement des corps
organises. 4to, Tome i, 1847. Tome ii (une fascicule),
1859, Atlas fol. 50 PI. Paris : Victor Masson.
5. Kolk, J. L. C. Schroeder van der (1851). Waar-
nemingen over het Maaksel van de menschelijke Placenta en
over haren Bloeds-omloop (p. 106 ff. — young human em-
bryo with two gill-clefts, Figs, on PI. ii). " Verhand. eerste
Klasse k. nederl. Inst. Amsterdam. Derde Reeks," 4 Deel.,
69-180, Tab. i-iv. (The reference to this paper is often
incorrectly given.)
6. Hennig, C. (1873). Ueber eines der jiingsten
menschlichen Eier und uber Fortbestand der Allantois.
"Arch. f. Gyn.," v, 169-173. Taf. ix.
7. Schwabe, Gustav (1879). Eine fruhzeitige mensch-
liche Frucht, etc. " Zeitschr. f. Geburtsk. und Gyn.," iv, 196.
8. Remy, Ch. (1880). Observation d'un embryon hu-
main long de un centimetre (measured stretched out?).
Robin's "Journ. d'anat.," 1880, 565. PI. XXI.
9. Ecker, Alexander (1873). Kleine embryologische
Mittheilungen. " Berichte iiber die Verhand. d. Natur-
forsch. Ges.," Freiburg i. B., Bd. vi, Heft ii, 116-120.
Taf. v.
Oct. 17, 1885.J
HYDE: FOUR GASES
OF TAITS OPERATION.
431
10. BRUCHr C. Untersuchungen iiber die Entwicke-
lung der thierischen Gewebe. (V. Ueber die Entwickelung
der Gewebe beira Menschen, Bd. vi, p. 247-310.) " Abb.
Senckenb. Naturf. Ges.," iv, 261-460. Taf. i-vi and vi,
185-310. Taf. 37-42. (Tafeln auch vii-xiii numerirt.)
11. Schultze, B. S. Das Nabelblaschen ein constantes
Gebilde in der Nachgeburt des ausgetragenen Kindes.
Leipzig, 1861.
12. Von Baer, C. E. Entwickelungsgecbicbte der
Thiere.
FOUR CASES OF TAIT'S OPERATION *
By JOEL W. HYDE, M. D.,
CONSULTING GYNAECOLOGIST AND OBSTETRICIAN TO LONG ISLAND COLLEGE
HOSPITAL ; CHIEF TO THE DEPARTMENT OF OBSTETRICS, ST. MARY'S HOS-
PITAL, BROOKLYN ; MEMBER OF KINGS COUNTY MEDICAL SOCIETY, AND
MEMBER OF THE BROOKLYN PATHOLOGICAL SOCIETY.
Tait's operation for tbe removal of the diseased uterine
appendages bas, during the last decade, passed through all
the stages of criticism by the profession, from that of as-
tonishment at its boldness and denunciation of the use of
so radical a treatment, to that of an almost universal ac-
knowledgment of its value.
There are still, however, a few medical men who shake
their heads and repeat the old threadbare arguments against
this operation which have been answered a hundred times
over, and, at last, with statistics so overwhelmingly convin-
cing, both as to the safety of the operation and its satisfac-
tory results, that few now deny it its proper place in sur-
gical history and science.
Battey first operated in this country (1872) for the re-
moval of diseased ovaries. His operations failed more fre-
quently of good results than those of the present day, as
he found that menstruation often continued uninterrupted.
To hold this function in abeyance was, moreover, the great
desideratum.
Tait afterward announced his belief that the Fallopian
tubes were an important factor in menstruation, and that
they should also be removed in order to bring about the
menopause more rapidly ; furthermore, this was necessary,
as the tubes were as likely as the ovaries to be the seat
of the disease sought to be remedied by the operation.
From this came the name of " Tait's operation " ; and
he certainly has the honor of having performed it a greater
number of times, and with less resulting mortality, than
any other living surgeon.
I have reported these cases for two reasons : 1. Because
the aetiology is, I believe, unique in at least two of them —
one being of malarial, and another of scarlatinal origin. 2.
In an operation of so recent adoption and of such gravity,
the most accurate statistics of all cases should be preserved
for future use.
I have, furthermore, purposely delayed this report for
several months that I might be able to give, not only the
history of the operations, but also the subsequent condition
of the patients.
Case I. — Mrs. M. M., American, aged twenty-nine, married
nine years.' Menstruated first at about fourteen years of age.
* Read before the Brooklyn Pathological Society, April 23, 1885.
Menses normal, except that they were profuse. At seventeen
she began to suffer much from dysmenorrhea, and her flow
was menorrhagic; still later it became metrorrhagia it often
being difficult to define the beginning or ending of a period.
At eighteen she had an attack of peritonitis, which was so
severe as to compel quietude in her room for months.
Subsequently her general health improved somewhat, and
she married. Her periods of intense suffering soon reappeared,
however ; her menstruation was "more irregular, and the pain
unfitted her for her ordinary household duties. Hystero-epilep-
tic attacks became frequent, followed by melancholia, at which
times she exhibited a suicidal intent, and was three times pre-
vented from taking her life by the watchfulness of friends.
I first saw Mrs. M. in June, 1883, and had her under
care for three or four months. Treatment availed nothing
except to mitigate her sufferings temporarily and disclose
fully the nature of her disease, which was diagnosticated as
chronic ovaritis of both sides, with salpingitis of the left
side.
Tait's operation was finally advised, and readily acceded
to by both patient and friends, as the only hope of future
relief.
Operation, November 11, 1883.— An incision of two inches
and a half was made in the median line, just above the pubes,
and the abdominal cavity opened. The peritonitic adhesions
were found to be so dense in every direction — all the viscera
being matted together — that it required the most patient dis-
section with fingers, knife-handle, and scissors, before the fun-
dus uteri could be reached ; this was found bound down with
the Fallopian tubes so firmly that it was necessary to increase
the abdominal opening sufficiently to pass in the whole hand,
to reach and tear the ovary from its bed of strong adhesions.
This accomplished, the tube was transfixed as closely as possible
to the uterus with a double silk carbolized ligature, one half tied
on each side, and the left ovary and tube removed. The right
ovary and tube were then sought and removed by the same
tedious process, and presented much the same appearance, ex-
cept that the cysts in the left ovary were larger than in the
right. The stumps were thoroughly seared with the galvano-
cautery. The left Fallopian tube was only a little over an inch
in length, much distended, and gave every evidence of the cor-
rectness of the diagnosis of salpingitis. The right tube was
about two inches and a half long, with some dropsical distension
near inner third. The wound and cavity were now carefully
cleansed with a two-per-cent. carbolized solution, great care
being taken to guard against any points of oozing, after which
the abdominal wound was brought together with nine deep
silver sutures and silk superficial sutures. The dressings used
were Am Ende's — naphthalinated dressings of cotton, cotton
gauze, and jute, completed with a flannel binder. Sickness at
the stomach was relieved by small quantities of hot water
sipped, and pain allayed by opium, large quantities of which
were used owing to her previous opium habit. This habit she
had entirely conquered by the third week, and has not resorted
to it since. The sutures were all removed by the tenth day.
Her temperature never rose above 100-75° F., and her convales-
cence was prompt.
She has recovered all her former cheerfulness of manner,
and, while not a robust person, is able to perform the duties
of her household with a fair modicum of comfort.
She still continues to menstruate, now eighteen months
after the operation ; but her periods, which, after the opera-
tion, were at first five days, have gradually grown to be
4-32
HYDE: FOUR CASES OF TAITS OPERATION.
[N. Y. Med. Joch.,
about one day in duration, and a greater lapse of time be-
tween tbem.
Case II. — L. J., American, aged twenty-seven, unmarried.
Menstruated first at sixteen, always irregularly and profusely.
Of late years she has suffered intensely with dysmenorrhoea,
headache, loss of appetite, and especially with pain in the region
of the sacral plexus. This pain has been of that character that
she has been unable to lie on her back for several years, and
what little sleep she obtained was in the genu-pectoral position
with pillows stuffed up hard against her abdomen. She was
treated for two years for spinal trouble by a specialist in New
York, but I have never seen any evidences of such a difficulty.
There is a very pronounced asymmetry of her body, but I learn
from her mother that it has existed from her infancy. The
mammary gland, the thigh, and leg of the left side were very
much smaller than the corresponding parts on the right side ;
in fact, the whole muscular structure of the left side presented
an appearance of atrophy.
There were great tenderness and pain over both iliac regions
for the greater portion of the time, a general weariness and in-
ability to do much or enjoy anything. She also had much men-
tal depression and a desire to resort to extreme measures for
relief. Examination revealed an enlarged and very tender right
ovary, with a prolapsed left ovary ; both tubal tracts very sen-
sitive. Tait's operation advised and performed November 19,
1883, at Long Island College Hospital. There were no adhe-
sions except a few which bound down the left ovary in its pro-
lapsed situation behind the uterus, and which were readily
separated ; this ovary was considerably less than normal in size.
Whether its small size was a part of the general asymmetry,
previously mentioned as existing in this case, is difficult to de-
cide, but I believe it to have been so. The right ovary was
enlarged and distinctly cystic, one small cyst being ruptured
while attempting to remove it. Both tubes were ligated as
closely as possible to the uterus with carbolized catgut, seared
with the cautery, and dropped back into the abdominal cavity.
The same kind of sutures and dressing were used as in the pre-
vious case. She was placed back in bed in forty minutes, and,
aside from some cystitis which developed the second week after
the operation, convalesced rapidly.
She left the hospital November 30th, traveling by rail
quite a distance to her country home.
Case HI. — Mrs. G., aged thirty-five years; married; sterile;
was always healthy and robust till seventeen years of age, when
she bad an attack of intermittent fever of great severity, the
effects of which lasted two or three years. Following this she
began to suffer with dysmeporrhcea, which every year increased
in intensity, and which later on was complicated with evident
attacks of localized peritonitis, both pelvic and abdominal.
There was some constriction of the vagina, and small bands of
adhesion ran between the cervix and upper vaginal walls on either
side. Coitus was intolerable ; and the most careful digital ex-
amination produced nausea and fainting, compelling her to keep
her bed for that day. As far as it was possible to learn from
an examination, there was great tenderness of the left ovary ;
the right ovary was undetected, but an undefined and fluctuat-
ing mass filled up that region of the pelvis, which was supposed
to be a cystic ovary. There was much less mobility of the
uterus than usual. Tait's operation advised and performed at
Long Island College Hospital, January 22, 1884. This opera-
tion was similar to the first in the vast adhesions everywhere
encountered, and which rendered the whole work, from the
first incision to the final touch, a blind and difficult dissection.
The left ovary was first sought and found imbedded in strong
adhesions near the side of the uterus. The Fallopian tube was
not over an inch in length, much thickened, and convoluted.
This was removed as closely as possible to the uterus and the
stump cauterized. In searching for the right ovary the greatest
care was used to separate the adhesions which densely involved
all the tissues of that locality. In this effort, however, a cyst,
as large as an orange perhaps, was ruptured. All efforts to
find the right ovary failed, and we adopted the belief that it
had degenerated into the cyst which had been so unfortunately
ruptured. No effort was made to dissect out the walls of the
cyst, which were strongly adherent to the bowels. The tube
was removed in the same manner as before mentioned. The
greatest caution was used in the toilet of the abdominal cavity,
and the wound was closed with eight deep sutures of silver and
Am Ende's dressings were applied. Although the operation was
lengthy and the patient exhibited some shock, she rallied well
the same afternoon, and, with a five-grain opium suppository,
passed a comfortable but somewhat restless night. On the fol-
lowing morning she spoke cheerfully to me, remarking her
freedom from pain. Pulse was 108, temperature 101°, respira-
tion 24. At noon, same day, she presented evidence of becom-
ing rapidly exhausted. Pulse 130, temperature 103°, respira-
tion 30. Death occurred thirty-one hours after operation.
No urine was voided by this patient after the opera-
tion.
The attempt to relieve the bladder with the catheter was
twice made, but resulted only in securing about an ounce
of turbid, bloody urine. The urine in this case had been
repeatedly subjected to rigid analysis, but nothing was re-
vealed which necessarily militated against an operation un-
less, possibly, the scanty amounts of solids found.
An autopsy was made fourteen hours after death. The
abdominal wound was apparently beginning to unite by the
first intention throughout its entire length, and all the deeper
structures presented a favorable appearance.
The kidneys were enlarged, and presented marked evi-
dences of fatty degeneration.
The right ovary was not found, and it was believed,
after a careful examination of the ruptured cyst, that it was
the product of degeneration of the ovary.
Death was undoubtedly due in this case to the condition
of the kidneys.*
Case IV. — Pyosalpinx. — E. H., twenty-three years of age,
single, very delicate, and of nervous temperament. Had suf-
fered almost from her first menstrual period, which began at an
unusually early age.
Two or three years prior to this she had a severe attack of
scarlet fever, followed by scarlatinal nephritis and dropsy. At
this time some of the pelvic pains seemed to have originated,
* The operation in Case III was delayed from week to week on ac-
count of renal insufficiency.
Random specimens of urine showed nothing abnormal ; but an ex-
amination of the total " out-put " for twenty-four hours invariably pre-
sented evidence of defective elimination of waste products.
Thus, for December 14, 1883:
Total quantity, 950 cubic centimetres ; specific gravity, 1'019 ; sol-
ids, 38 grammes; urea, 19*5 grammes.
Acid ; no albumin ; no sugar ; little coloring matter ; oxalate of
lime and a little pus in the sediment.
Numerous subsequent examinations merely served to verify the first
analysis. The condition of the patient grew more and more unsup-
portable, and it was finally decided to grant her petition for the & rni* r
ressort.
Oct. 17, 1885.]
HYDE: FOUR CASES OF TAITS OPERATION.
433
which, later onf as menstruation developed, became the more
acute and fixed pains of her present disease.
I may say here, parenthetically, that, if scarlet fever can in-
vade one portion of the genito-urinary apparatus, I think it fair
to assume that other portions may also be affected, and I see no
reason why the ovaries and Fallopian tubes should be exempt.
In this case menstruation was irregular — generally at inter-
vals of about three weeks — and rarely lasted less than ten days.
ITer suffering at these times evoked the pity of all her friends,
and they sought relief for her from numerous members of the
profession. All the characteristic symptoms of localized pain,
reflex irritation, nervousness, and weakness, which are indica-
tive of ovarian and tubal disease, were abundantly manifest.
Two unusual concomitants of her disease attracted my atten-
tion :
First. As her periods approached, the lymphatic glands of
the lower portion of her body and thighs became tender, and,
in a day or two, this was followed by a general tumefaction of
all the adjacent tissues. The labia were two or three times their
normal size, and both limbs were swollen and painful to move.
The inguinal region was specially sensitive. This seems to have
been a rhythmic neurosis, dependent entirely upon the regular
periods of pelvic engorgement and excitement to reproduce it.
Second. After the second or third day of menstruation the
discharge w'ould vary at times from the normal appearance
and become muco-purulent and exceedingly offensive — so much
so as to suggest the foetid odor of malignant disease.
These two conditions would be maintained to the close of
each period, then subside, giving no further inconvenience till
the succeeding period.
Examination in this case revealed the cervix pressing against
the neck of the bladder and rather firmly fixed by previous in-
flammatory processes, moderate retroflexion with prolapsus of
left ovary, and great fullness and tenderness over tubal tracts
and ovaries.
Operation, March 3, 1885. — This was accomplished rapidly.
Some evidences of chronic pelvic peritonitis, deep-seated, but
not sufficient to delay materially the operation. Both ovaries
slightly enlarged, intensely engorged, and full of small cysts.
These were removed, together with the tubes, as close to the
uterus as it was possible to clamp and ligate.
Recovery from the effect of the operation was exceed-
ingly prompt. The wound healed by the first intention,
the temperature or pulse never rising above 100°.
Three months have elapsed now, and she has had no
return of menstruation, beyond a slight molimen which ap-
peared for two or three days after the operation. She,
however, suffered from an attack of the rhythmic neurosis,
previously mentioned, when her first month came around,
but it was confined to one leg only, rather than both, as
heretofore. This neurosis will probably soon cease entirely,
as it is hoped and believed the majority of her previous dis-
comforts will do.
Resume. — There were four patients — two married and
two unmarried.
Three lived, one died.
Two had extensive peritonitic adhesions ; two had none.
. Two have never menstruated since they were operated
upon. One has continued to menstruate till the present
time (about eighteen months), although the function has
about ceased.
The one in whom the menstrual function has continued
was one in whom the adhesions were very extensive ; and
perhaps this fact alone may have a bearing on the question
of her prolonged menstruation. The two in whom the
function ceased so promptly had no adhesions.
The prominent features of these cases are :
Case I. — Hystero-epilepsy. The prolonged menstrua-
tion after the operation.
Case II. — The asymmetry of the body.
"Case III. — Salpingitis resulting from very severe mala-
rial attack. Death from unsuspected renal disease.
Case IV. — Scarlatinal pyosalpinx.
The case of the last patient was particularly instructive
from the peculiarities of the rhythmic neurosis and the foetid
discharge mentioned. I regret that I did not subject this
discharge to Professor Ferguson's microscopical test for
columnar ciliated epithelium, as it would have probably
decided the question whether it was a drainage from a
pyosalpinx, or the offensive discharge and detritus of a
dysrnenorrhoeal membrane.
There appears to have been no special or positive evi-
dence of gonorrhceal infection in a single one of these cases.
I fully believe in the correctness of Dr. Noeggerath's state-
ment, that there are great numbers of women who suffer
from inflammations of the uterus and its annexa as a result
of latent gonorrhoea, and I have now under my care ladies
whose history makes it almost positively certain that their
cases belong to this class ; but the cases reported in this pa-
per show that a considerable proportion at least may be
autogenetic.
Mr. Lawson Tait has remarked that cases of diseased
ovaries and oviducts can be relieved by nothing short of
removal of the diseased organs; moreover, that these cases
exist in great numbers, forming a large proportion of those
in which the patients wander about from one practitioner
to another seeking relief.
Mr. Tait has also supplemented this affirmation with a
recent history of a large number of cases in which he has
successfully removed the uterine appendages.
In the treatment, internal medication is practically value-
less ; nevertheless, we temporize with these cases for a while,
using every fair endeavor to relieve pain and restore the
function to a normal state. In early cases, where the
patients are surrounded by every comfort and care, some
are relieved, but the mass of them never find relief short of
an operation.
In the study of Tait's operation and the causes which
have demanded so heroic treatment the whole profession
must be interested. They are no longer obliged to turn
away women who beg for something — anything — to relieve
their sufferings, by telling them " there is nothing more
that can be done for you."
I believe there is scarcely an operation known to sur-
gery which invites better ultimate results ; the only trouble
is, they expect these good results too soon.
This operation results in a climacteric to the patient. I
think as much time should be allowed for a full recovery of
the general health after an operation of this nature as would
be required in the case of an ordinary natural climacteric.
There are few women who do not feel nerve and pain dis-
comforts for many months at the menopause, and these dis-
434
THAYER:
UMBILICAL HEMORRHAGE.
[N. Y. Med. Jouk.,
comforts are in exact ratio to the amount of possible disease
existing in the uterus and its appendages at that time.
Since to bring about a menopause at an earlier age, by
an operation for a disease, is an unnatural change, we may
readily realize that at least as much time should be allowed
for general recovery in the latter case as in the former.
I have been forcibly impressed with the enthusiasm with
which the few upon whom I have performed this operation
have accepted this serious alternative ; in fact, after a short
consideration of the subject, they have been unwilling to be
put off with any other suggestions ; they immediately see
something tangible in this and are willing to risk their lives
for the great stakes.
Fortunately, we are able to encourage them with almost
a certainty of success.
All of these patients who are living have already demon-
strated the success of the operation upon them. I happen
to have seen during the past month two of them who live
out of town ; while neither is robust, both are free from the
terrible distress in which they languished for so many
years.
UMBILICAL HJEMOKRHAGE *
By WILLIAM HENRY THAYER, M. D.,
BROOKLYN.
Mrs. N., a young married woman, was delivered of her first
child March 17, 1885. Both parents are healthy; the labor was
normal, and the child apparently in normal condition. Its
evacuations were sufficient, and the discharge from the bowels
presented the usual appearance of meconium for four or five
days. At the termination of the sixth day, March 23d, a. m.,
the nurse called my attention to its alvine evacuation, which
was of a light slate-color, and its urine was slightly yellow. Its
skin was slightly jaundiced. The child had taken the breast
well, and had not vomited. The cord had not separated.
That afternoon there was a sudden and profuse haemorrhage
from the base of the cord, then beginning to separate. In my
absence, Dr. G. R. Westbrook was summoned, and, failing to
arrest the haemorrhage with styptics, pinched up a fold of the
skin and ligated it. At 10 p.m. I gave one grain of calomel
At 4 a.m., 24th, the haemorrhage began again, and, as I was ill,
Dr. Westbrook saw the patient for me and repeated the liga-
ture. I saw the child at 9 a. m. There was no haemorrhage,
but she was very pallid, and had had no dejection. I then pre-
scribed 3 jss. of castor-oil, and repeated doses of brandy and
water. At 1p.m. I was called, to find her again bleeding. The
ligatures had not held; the cord was almost entirely separated,
exposing a raw surface as large as a thumb-nail, livid, sodden,
and with no appearance of coagulating. She had had several
slight dejections, of nearly the same color as the day before,
and she was extremely pallid and feeble. I transfixed the skin
with surgeons' needles, two in the direction of the median line
and one transversely, and around these I bound ligatures of
silk, entirely controlling the haemorrhage. But within an hour
the patient began to sink, and died, without convulsion, at 7.30
r. it.
I assisted Dr. Westbrook in an autopsy at nine o'clock the
next morning.
The intestines were much distended with gas ; the stomach
contained a little milk; the liver presented externally a normal
Appearance; the gall-bladder contained no bile, but only a small
* Head before the Brooklyn Pathological Society, April 23, 1885.
amount of mucus. The hepatic duct was pervious part of the
way from the liver to the junction of the cystic duct; but its
lower half and the entire length of the common duct were ap-
parently an imperforate cord, as large as a coarse thread, and
evidently impervious, as attempts to inflate it with a blow-pipe
introduced into the gall-bladder were unsuccessful. The kid-
neys, heart, and lungs were normal in appearance.
The literature of this subject is confined to the last
forty years, with the exception of two or three reports of
single cases of fatal umbilical haemorrhage, the earliest of
which is by Mr. G. Watts, an English surgeon, in 1752.
Dr. Cheyne published a case in Edinburgh, in 1801, of
fatal umbilical haemorrhage, with jaundice; and suggested
that " the bleeding proceeded from the unhealthy change
produced in the blood by the reception of the bile into the
mass of fluids."
Since 1850 four papers have been published on the
subject, based on cases collected from many sources. They
are : One by Dr. Henry I. Bowditch (" Amer. Journal of the
Medical Sciences," 1 850), including twelve cases ; Dr. Francis
Minot (" Amer. Journal of the Medical Sciences," 1852),
forty-six cases ; Dr. Stephen Smith (" N. Y. Journal of
Med.," etc., 1855), seventy-nine cases; and Dr. J. Foster
Jenkins ("Trans. Am. Med. Asso.," 1858), one hundred and
seventy-eight cases. I think Dr. Jenkins's report includes
all the cases reported by the others. Dr. Jenkins says that
in the Foundling Hospital at Paris, in 9,000 births there
was only one case of umbilical haemorrhage ; in the Dublin
Lying-in Hospital, in 6,654 births there were no cases ; in
the Emigrant's Refuge at Ward's Island, in 2,000 births
there were two cases ; in the practice of Dr. Charles Hook-
er, of New Haven, in 2,879 births there was one case; in
the practice of Dr. Elisha P. Fearing, of Nantucket, in
4,000 births there was only one case. That is, in 24,533
births only five cases of umbilical haemorrhage.
In Dr. Jenkins's table of one hundred and seventy-
eight, most of the reports are incomplete. In thirty no his-
tory is given, except the facts of haemorrhage and death.
There were only twenty-two autopsies. Most of the report-
ers had do suspicion of the cause of the haemorrhage; even
in some of the autopsies the bile-ducts were not examined ;
the haemorrhage was often attributed to patency of the um-
bilical vessels, and their condition is sometimes carefully
noted. It is also frequently charged to a haemorrhagic dia-
thesis. Thus, Dr. Minot says : " Idiopathic haemorrhage
from the umbilicus is only one of the various manifestations
of the haemorrhagic diathesis, which in other cases is ex-
hibited in bleeding from the gums, stomach, intestines, etc.,
and in the appearance of purpuric spots beneath the skin ;
in proof of this, we see the concurrence of these phenomena
with umbilical haemorrhage."
Now, in regard to these expressed opinions, it is to be
said that closure of the umbilical vessels is chiefly the cica-
trization of their orifices, which depends upon normal co-
agulation of blood ; so that we must not stop at open ori-
fices for the cause of the hemorrhage, but inquire into the
abnormal condition of the blood which interferes with its
coagulation. It is probable that jaundice was present in all
the cases. True, of the one hundred and forty-eight of Dr.
Oct. 17, 1885.1
THAYER: UMBILICAL HAEMORRHAGE.
435
Jenkins's cases in which any history is given, jaundice is
mentioned in only seventy -seven ; but Dr. Jenkins says that,
"from the imperfect manner in which some of the histories
are furnished, it is probable that a much larger proportion
would be found in more fully recorded observations. Ninety-
three per cent, of all who were reported to have jaundice
died." Jenkins says : " It is a well-established fact that in
almost all cases of jaundice the blood becomes much impov-
erished, the globules and the fibrin falling below the natural
standard, and, consequent upon this impoverished state of the
blood, a general disposition to haemorrhage very commonly
exists." Von Schueppel, in his article on the biliary pas-
sages ("Ziemssen," ix, 610), says: "The signs of a haemor-
rhagic diathesis will rarely be missed in the long-continued
icterus which is due to occlusion of the gall-duct. In many
individuals, especially in very small children, the tendency
to haemorrhages makes itself felt soon after the beginning
of jaundice."
In the twenty-two autopsies, the bile-ducts were exam-
ined in only eleven cases ; in seven they were absent or im-
pervious ; in four they were open, but the liver was in an
abnormal condition ; in the cases where the ducts were per-
vious icterus had existed, with whitish dejections and bil-
ious urine — indicating want of secreting power in the liver,
although there was no impediment to its passage into the
duodenum.
" Haemorrhagic diathesis " is a misleading term, when
the haemorrhage is due to an accumulation of bile in the
blood, whether from absence of the ducts or their complete
obstruction with inspissated mucus, or to some abnormal
condition of the liver which causes a suspension of its func-
tions. Dr. Jenkins says : " Of families known as ' bleeders,'
where the slightest injuries often induce serious haemor-
rhage, scarce any record exists of infantile umbilical bleed-
ing." Instead of a haemorrhagic diathesis in the cases
which are the subject of this paper, there is sufficient evi-
dence already adduced that the cause is in the liver or its
ducts.
Among the cases reported by Dr. Jenkins are those of
thirty-nine children of seventeen mothers, each of whom
bore more than one child who had umbilical haemorrhage.
No one of these mothers had exhibited any haemorrhagic
tendency ; many of them had borne other children who had
no haemorrhage. In nineteen of the cases jaundice is re-
ported present. In only two cases is it expressly stated
that there was no jaundice, but in these cases, which were in
twins, death occurred in seventy-two hours after birth from
haemorrhage through the unbroken surface of the cord; * in
four cases of the six which were examined post mortem the
ducts were found impervious ; two of these were in children
of the same mother. All the evidence we get from these
cases shows a tendency to biliary obstruction, which may
exist in certain families, rather than a haemorrhagic diathe-
sis.
An occasional cause of fatal umbilical haemorrhage is
acute fatty degeneration near the close of foetal life, includ-
ing the heart, lungs, liver, and kidneys, the blood-vessels
breaking down everywhere, with resulting haemorrhages.
* Probably from general fatty degeneration, as in Dr. Jacobi's ease.
Such a case was reported by Dr. Mary Putnam Jacobi, in
which haemorrhage began four hours after birth, and death
occurred in less than twenty-four hours. Dr. Jacobi quotes
Hecker and Buhl as describing this disease in 1861 (" Am.
Jour, of Obstetrics," July, 1878).
In addition to a certain proportion of cases which are
hopeless, from absence or obliteration of the common duct
or the hepatic duct, or from the general fatty degeneration
just referred to, there are many in which the ducts are
plugged with inspissated mucus, or closed by thickening of
the mucous membrane, the result of catarrhal inflammation,
to which relief may come spontaneously or by medical
treatment. Of one hundred and seventy-eight patients,
thirty recovered, and many of the fatal cases were of such
a character that recovery would have been possible — that
is, the obstruction was of a temporary nature.*
It is safe to conclude that in cases of umbilical haemor-
rhage in new-born children, attended with jaundice, the
cause of the haemorrhage is usually the accumulation of bile
in the blood, produced by obstruction of the hepatic or
the common duct, or by an abnormal condition of the
liver.
As to the general history of these cases, haemorrhage
began at the root of the cord, either when the separation
commenced or within a few days after ; the average time
was the eighth day, but in seven cases it did not begin til^
the third week ; in one case eight weeks from birth. Dr.
Murchison, in his work on " Diseases of the Liver," relates
the case of a child who died at the age of four months and
a half, having had jaundice from its first week, with pro-
gressive emaciation, after a while diarrhoea, the discharges
being perfectly white, frequent epistaxis, vomiting of blood,
and ecchymoses under the skin, ever increasing in number.
The bile-duct was found to be completely obliterated, its
place being occupied by a small quantity of areolar tissue.
The average duration of the haemorrhage in the fatal
cases was three days and a half. In a large proportion of
the cases there was jaundice several days before the haemor-
rhage began ; in many of them purpura, either before or
after the haemorrhage, and passages of blood from the stom-
ach or bowels. Constipation was frequent ; the stools were
white or clay-colored ; the urine was deeply stained with
bile.
As to treatment, the first indication is to transfix the
integuments at the base of the cord with needles, and carry
a figure-of-eight ligature underneath them. Styptics and
compression are of no avail. But Dr. Jenkins, who advo-
cates the ligature, cautions us not to stop with that, but to
use such internal remedies as may relieve the liver, where
no anatomical malformation exists. Chief of these are
nitro-hydrochloric acid and tincture of the chloride of iron,
with cathartics, especially calomel.
* Illustrative of a fatal closure of the bile-ducts with inspissated
mucus, I recall the case of an infant who died a few days after birth
with symptoms of intestinal obstruction, at whose autopsy I found com-
plete closure of the ileo-ea?cal valve, the entire small intestine being
distended with gas, and the whole large intestine completely empty and
contracted. It was at first supposed that the intestine was impervious
by malformation, but washing removed an accumulation of mucus and
disclosed the valve in a normal state.
±36
BLISS: BILIARY AND RENAL CALCULI.
[N. Y. Med. Joik.,
THE DUCTUS CHOLEDOCIIUS COMMUNIS
OBSTRUCTED BY A CALCULUS;
JAUNDICE; DEATH; NECROPSY; REMARKS*
By H. D. BLISS, M. D.,
BROOKLYN.
The case occurred in St. John's Hospital. The clinical
history is kindly furnished me by Dr. R. L. Casburn, the
house physician, from his notes :
History. — November 1, 1885, Frank W., a German, aged
sixty-five years; history good; no sickness except as noted
below. Has been for two or three years an assistant in the
male ward. He. was admitted to the hospital for the treatment
of a large varicose ulcer of the leg of many years' standing. It
encircles the leg to within an inch, is of irregular shape, and
varies from one to four inches in breadth. The ulcer proved
very intractable, and remains now probably in about the same
condition as when he entered the hospital. This is his only
complaint, and causes him remarkably little trouble. The pa-
tient is a well-preserved man for his age ; is about five feet and
a half in height, weighs 180 pounds, and has a tendency to be-
come obese.
About this time, November 1st, he was taken with a sudden
attack of marked jaundice. The accompanying symptoms were
not such that an accurate diagnosis of its cause could be made.
After the jaundice became very marked there were nausea,
anorexia, slowness of the pulse, constipation, clay-colored stools,
and high-colored urine. There was no enlargement of the liver,
and no tumor that could be detected. He complained of no
pain anywhere, unless it was a slight headache. There was not
even tenderness over the hepatic region. Dr. William Wallace,
attending physician on duty, thinking it might be due to torpid
liver or catarrhal condition of the common bile-duct, applied
blisters over the site of the duct and gave calomel freely ; at
first it seemed to avail nothing ; after about two weeks the
jaundice suddenly commenced to give way and soon entirely
disappeared, and the patient was as well as ever. He re-
mained quite well until December 10th, when another attack
of jaundice suddenly came on, like the previous attack, ac-
companied by all the symptoms which necessarily accompany
jaundice from any cause, but by no symptoms from which a
special cause could be diagnosed. The same treatment was
instituted as before, but, as he got no better, it was changed to
acid, nitro-hydrochlo. dil., nixv, t. i. d., and cloths saturated with
a lotion of the same were applied to the region of the liver.
This was continued for about a week with no improvement.
Treatment was then changed to R Sodii phosphatis, 3 j, t. i. d.,
dissolved in a glass of water ; this was persisted in for two weeks
without any apparent result. The troublesome symptoms had
all increased; the jaundice was about as marked as it could be;
the appetite entirely gone ; nausea was constant ; bowels consti-
pated, except when violent cathartics were employed ; stools
clay-colored all the time; urine very high colored ; pulse slow,
fifty and under. Patient becoming emaciated, and certainly fail-
ing slowly.
On January 16, 1885, between five and six weeks from the
time of the present attack, a consultation was held by Dr. William
Wallace, Dr. Arnold W. Catlin, and Dr. Frederick H. Colton,
attending physicians to the hospital. It was decided that small,
often-repeated doses of the mild chloride be given and pushed
to slight salivation. Accordingly, gr. was given every hour.
* Read before the Brooklyn Pathological Society, March 12, 1885.
But the jaundice did not yield in the least, even with the touch-
ing of the gums.
From this time on the symptoms only were treated, the pa-
tient being made as comfortable as possible ; but he kept grad-
ually failing, and died on February 13, 1885 — a little over two
months from the beginning of the second attack.
Necropsy. — The body was much emaciated. On opening
the thoracic cavity, the heart was found normal, the lungs crepi-
tant throughout and normal, except a few old pleuritic adhe-
sions. The abdominal cavity, on inspection, showed that the
liver was not enlarged, and was natural in color. The intes-
tines were light in color, almost a grayish white. On examina-
tion, the gall-bladder was found to be distended, but not en-
larged, and of a dull, muddy color. On opening the bladder, it
was found to contain a brownish, muddy-colored fluid of greater
consistence than bile. Further examination revealed a stone
encysted in the common duct. It could not be pushed forward
or backward, and acted as a ball-valve ; the walls of the cyst m
were a pyogenic membrane, and the stone was bathed in pus.
The stone was a regular ovoid, a little over three quarters of an
inch in the longer diameter, and a little less than three quarters
of an inch in the shorter diameter, roughened on the outside,
with elevations like small grains of sand, with the angles worn
off. The stone was as hard as an ordinary marble, and, after
being thoroughly dried, sunk readily in water.
The stomach was contracted ; the intestines contained a
quantity of thick, putty-colored material ; spleen normal ; pan-
creas elongated and narrow. The kidneys contained many cysts
between the parenchyma and capsule of the size of a five- cent
piece to a twenty-five-cent piece, containing a clear fluid. In
the pelvis of the right kidney was a calculus, and in the left two
calculi, irregular in shape, smooth, and slate-colored, measuring
about half an inch _on the longest facette. The organs not men-
tioned were normal.
Remarks. — The question now presents itself, What ad-
ditional means could have been employed to assist in mak-
ing a diagnosis, and, had a diagnosis been made, how would
it have affected the treatment ? Bartholow (Pepper's " Sys-
tem of Medicine," vol. ii, p. 108) says he has "punctured
the gall-bladder with a fine exploring trocar, removed the
contents, and explored the interior without damaging the
organ." Had this been done, it is doubtful if the stone
would have been discovered. On account of the hardness
of the stone, it would have been impossible to dissolve it
had it been discovered. The question is, All other means
failing, would abdominal section have been justifiable?
Henry Morris (" International Encyclopedia of Surgery,"
vol. v, p. 886) says : " Laparotomy, followed up by suture
or removal of the gall-bladder, ought, in certain cases, to be
adopted." Again, page 1071 : " In cases of distension with
pus and calculi, and in those instances of accumulation of
bile or mucus, in which other remedies have failed, opera-
tive measures will be required."
It may also be worthy of note that there had been
no pain ; and that during life there had been no signs refer-
able to the kidneys, and examination of the urine gave no
evidence of the renal calculi.
57 Madison Street.
An Anti-Vaccinator. — It is said that one Dr. Ross, who has caused
much trouble in Montreal, was found, on being made to bare his arm,
to have not only marks of former successful vaccinations, but evidences
of one of recent date.
Oct. 17, 18«5.]
EOLIPINSKI: APHONIA SIMULATED IN THE YOUNG.
437
APHONIA SIMULATED IN THE YOUNG.
By LOUIS KOLIPINSKI, M. D.,
CHILDREN'S HOSPITAL, WASHINGTON, D. C.
The following cases are reported to illustrate the feign-
ing of disease by the young. They further show the im-
possibility of impressing upon alarmed and anxious relatives
the truth of such deception, and may finally remind the
practitioner, called in haste, that, instead of a disease, he
may merely have an impostor to treat.
A female mulatto of eighteen was presented by her lover,
with the statement that she had been suddenly seized with loss
of speech on the preceding night, and that she had not since
uttered syllable or sound. A careful examination of her gen-
eral health, past and present, did not disclose any cause for the
aphonia. Her hearing was normal, and she readily responded
to questions in writing and by signs. Neither she nor her com-
panion gave the least support to the suspicion of hysteria as the
cause. Her facial expression was calm and composed, and
there was no outward evidence of uneasiness or fear.
Iu the absence of every conceivable factor of a genuine
aphonia, I concluded that it was a case of malingering with the
purpose of exciting the alarm and sympathy of some one. Act-
ing on this presumption, her escort was excluded from the room
and the attempt made to loosen her tongue by persuasion.
All efforts failed ; there remained but the last resort of intimi-
dation. She was assured that repeated applications of a laryn-
goscopy throat mirror sufficiently heated would restore her
voice. She bore a few introductions with considerable courage,
but soon perceiving, by the persistency of the applications, that I
was confident of success, she at last began speaking in mono-
syllables, and, in conclusion, narrated the cause of her trouble
as the result of a quarrel with her lover. All efforts to make
her confess that her silence had been only voluntary were use-
less. Her companion, who had exhibited the utmost solicitude
for her, was overjoyed at the speedy cure.
I was called to see a negro boy of eight years who had be-
come suddenly mute a few hours before. The other members
of the house were much alarmed, and the mother was so agi-
tated that it was with difficulty that a history could be obtained.
The boy had recently had Rotheln, which was followed by a
bronchitis, but was thought to have recovered. Nothing had
occurred, my informant said, that could have possibly induced the
child to become mute either from anger or disappointment, and
yet a search for other causes was fruitless. The patient lay on
a couch placid and at ease. Recollecting the experience in the
former case, I became convinced that this was a similar one.
The room was therefore cleared, and I attempted to elicit a
word by a variety of arguments and questions. The result was
a signal failure. The boy maintained a stolid look and an-
swered only with motions of the head. A forcible introduction
into the mouth of a spoon-handle and the threat of a hot iron
were of more avail. In his alarm he began to cry for his
mother. She, however, could not be made to believe that the
boy had been feigning, and her surprise and pleasure at his re-
covery were only equal to her first distress.
Both cases were from a low class of society. The dis-
similar ages, the negative characters of their histories, and
the bearing of the patients were sufficient to exclude any
disease or morbid state in the causation. It was apparent
that the object of the sudden and complete loss of speech
was intended to excite the alarm of their connections, and
thereby gain some point by awakening solicitude. It was
impossible in the boy's instance to confirm this by individu-
al statement of mother or child.
But, whatever the motive, the malingering was success-
ful, for it was soon evident to me that the superstitious
minds of the interested ones were proof against every as-
surance that the aphonia was not real, and that they had
been deceived.
To conclude, the mutism which both selected as the
startling affliction is the most natural one imaginable. The
patients were not sufficiently cultivated to counterfeit some
disease requiring knowledge and judgment for skillful imi-
tation, as, for example, blindness or deafness. Children of
a bashful disposition, as everybody knows, are mute in the
presence of strangers, and our subjects simply repeated
what they perhaps had often practiced before, but from
different motives. It was the half-voluntary, half-instinc-
tive act of an uneducated mind.
ook Notices,
Topograph ical Anatomy of the Brain. By J. C. Dalton, M. D.,
Professor Emeritus of Physiology in the College of Physi-
• cians and Surgeons, New York, and President of the . Col-
lege. Philadelphia: Lea Brothers & Co., 1885. Three Vol-
umes, 4to, pp. vii-56 ; iv-59 to 104, inclusive ; iv-115 to 175,
inclusive. Heliotype Plates.
This work is unquestionably one of the most creditable con-
tributions ever made to the study of the anatomy of the brain.
We know not which most to admire — the beautiful execution
of the heliotype reproductions from photographic negatives
made under the author's supervision from fresh preparations of
his own, or the skill that arranged the preparations in such
manner as to make them tell their story so effectively. From
either point of view, the work is altogether beyond criticism.
"We can only express our satisfaction that, after years of labor
as a teacher, the pioneer of experimental physiology in America
should have found time to finish such a great undertaking — one
that will go far toward wiping away from our medical litera-
ture the reproach that it ignores research and lends itself only
to that which makes a direct practical appeal to the multitude.
Not the least satisfactory part of the work is that in which the
author describes his methods of making parallel sections of the
brain — a portion that is very effectively illustrated with wood-
cuts. The publishers are deserving of the greatest praise for
the appearance of the volumes.
BOOKS AND PAMPHLETS RECEIVED.
The Science and Art of Midwifery. By William Thomson
Lusk, A. M., M. D., Professor of Obstetrics and the Diseases of
Women and Children in the Bellevue Hospital Medical College,
etc. New Edition, Revised and Enlarged. With Numerous Il-
lustrations. New York : D. Appleton & Co., 1885. Pp. xviii-
763. [Price, cloth, $5 ; sheep, $6.]
The Esseutials of Histology, Descriptive and Practical, for
the Use of Students. By E. A. SehSfer, F. R. S., Jedrell Pro-
fessor of Physiology in University College, etc. Philadelphia:
Lea Brothers & Co., 1885. Pp. viii-245.
Laparotomy for Ovarian Cyst. By A. W. Leighton, M. D.,
New Haven, Conn. [From the Proceedings of the Connecticut
Medical Society, 1885.] Pp. 4.
438
LEADING ARTICLES.
|N. Y. Mki>. JotK.,
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Pnbliahed by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, OCTOBER 17, 1885.
NO MORE CODE CONTROVERSY.
In this issue of the Journal we print a letter which deals
with a subject that we have long considered a good one to be
let alone, so far as public discussion of it is concerned. On
that account we have for many months past uniformly declined
to publish letters on that subject, no matter what ground was
taken in them, and we now make this solitary exception, first,
because Dr. Black's letter seems to embody only the convic-
tions of a pure-minded man who has no axe to grind, and
whose purpose does not appear to include any attempt to crack
the code whip, and, secondly, because we believe our corre-
spondent to be so conscientious as readily to admit to himself
that he may possibly have given Dr. Jacobi's remarks a wider
application than their author really intended. We do not doubt
that Dr. Black's ideas as to the propriety of consultations with
so-called homoeopathists— using the word consultation in its
legitimate meaning— are quite in accord with those held by, as
he says, " ninety per cent.," not only of the physicians of his
own region, but of those of the whole country, including an
overwhelming majority even of the new-code men. We be-
lieve, moreover, that Dr. Jacobi would be among the last to
advocate such "consultations." But no man's position on that
abstract question can quite cover the field that has been the
ground of the contention in this State, and we consider it an
utterly hopeless task to attempt to make that field clear to our
brethren in other parts of the country. For that reason we
deprecate any further controversy in the matter. The New
Yrork code has now been in operation for three or four years.
Let its working be kept under observation for five, ten, fifteen,
or twenty years more; and then let the question be decided
whether its effect has been good or evil. Meantime, let there
be no further contention from theoretical points of view, and
let there be no more attempts to ostracize men because of their
opinions on the question, be they what they may. For our
part, so far as public controversy is concerned, we shall regard
the code as a dead issue.
A GERMAN CRITICISM OF AMERICAN MIDWIFERY.
It is generally felt to be an occasion for regret when one
has to quote an author at second hand. Especially is this held
to be the case when the subject treated of relates to science.
Most of all to be avoided is criticism founded on a second-hand
quotation, particularly when the version drawn upon does not
purport to give the original in full, but only in abstract. We
regret that on such a flimsy foundation a contributor to one of
our most valued German contemporaries has recently seen fit
to indulge in criticism of a New York practitioner.
In our issue of April 26, 1884, we published a report of the
proceedings of a meeting of the New York County Medical
Association, including a summary of a paper, by Dr. Charles A.
Leale, entitled "Scarlatina of the Foetus in Utero and of the
Mother at the Ninth Month of Pregnancy." In this paper Dr.
Leale gave the history of a case, in the course of which he
said : " The foetus, from its violent motions, appeared to be in
convulsions. The mother became delirious. It was considered
necessary to deliver quickly in order to save either the mother
or the child. The cervix was accordingly dilated, and within
four hours the forceps was applied and the child extracted,
without injuring mother or child."
The "Revue de medecine " for July, 1885, summarizes our
account of the history of the case, and says : " Le fatus s'agi-
tant beaucoup et paraissant en convulsions, on fit la dilatation
du col et on put extraire V enfant sans dommages ni pour lui ni
pour la mire.'''1 This is correct, so far as it goes, but it omits
the sentences which showed that rapid delivery was considered
essential to the mother's safety, and that that opinion was well
founded on the clinical facts. As regards the accouchement
force, our French contemporary implies — which evidently was
all that Dr. Leale meant to say — that the processes of dilata-
tion and extraction did not injure either the mother or the
child.
The " Deutsche Medizinal-Zeitung " gives the following
translation of the French journal's words: " Da der Fdtus sich
sehf starh bewegte und Kontulsionen zu haben schien, machte
man die Dilatation des Kollum und Jconnte das Kind extrahiren,
ohne Schaden fur Mutter und Kind.'''1 To judge from this ac-
count— and we admit that it is a perfect translation of the
French version — accouchement force was performed solely in
the interest of the child, the statements as to the mother's des-
perate condition not having found a place in the French sum-
mary of Dr. Leale's remarks. Thus far, then, the German jour-
nal is simply proceeding upon insufficient information, and it
might perhaps be held that, in the absence of the full statement
of the facts, it would have been justified, but for the manifest
impropriety of founding any criticism upon a mere summary, in
questioning the propriety of the resort to forcible delivery.
But we are unable to see that anything can warrant its assump-
tion that the mother's death was in any way incompatible with
Dr. Leale's statement that the operative procedures resorted
to were accomplished " without injuring mother or child."
But it is on that assumption that it seems to have founded
the following remark: "(Und da soil die amerikanisch in-
dizirte forcirte Entbindung ohne Schaden fur die Mutter gewe-
sen sein ? ! !) "
Damaging as the phrase " amerikanisch indizirte" the note
of interrogation, and the two exclamation marks may appear
to the German mind, we would like to ask our Berlin contem-
porary if it regards the death of a patient who has been oper-
ated on as necessarily indicating that the operation was the
cause of the fatal result.
Oct. 17, 1885.|
MINOR PARAGRAPHS.
439
MINOR PA RA GRA PES.
THE TENNESSEE " STATE BOARD OF HEALTH BULLETIN.''
We have received the first number of this periodical, for the
month ending- July 31, 1885. It seems to owe its origin to the
fact that the publication of the monthly meteorological report
of the State (which wa9 formerly published with the crop re-
ports, by the Bureau of Agriculture, Statistics, and Mines, and
more recently in an agricultural newspaper) has lately been
turned over to the board. The board therefore concluded to
couple its weather reports with matters more properly apper-
taining to its own sphere of action, and the result is this pam-
phlet of twelve pages of reading matter. We regret to see that
the appropriation made by the State for sanitary purposes was
so small as to compel the board to admit advertisements into
this, a public document. Sanitary information ought certainly
to be diffused as generally and as systematically as possible;
hence the State would find its account in not being niggardly
in the matter of this excellent publication.
THE NEW VOLUME OF THE INDEX-CATALOGUE.
TriE appearance of the sixth volume of this great work is a
fresh reminder of the wonderful zeal with which it has been
prosecuted, and it is almost superfluous to say that it reveals
the same painstaking accuracy that marked the preceding vol-
umes. The work is now brought down to the word Insfeldt.
The additional list of medical periodicals drawn upon fills eleven
of the large pages, and shows the completeness with which
contemporary periodical literature is indexed. The work is
simply stupendous, and we can only repeat the expression of
our sense of the obligation under which the whole profession
ought to feel itself to Dr. Billings and his associates in the un-
dertaking. We may now reasonably look forward to the com-
pletion of the catalogue in the course of a few years more, and
it is earnestly to be hoped that the Government will do every-
thing in its power to hasten its publication.
THE DISINFECTION OF IMPORTED RAGS.
No doubt there has been some needless quarreling over the
matter of the disinfection of foreign rags entered at the port of
New York, but it must be conceded, we think, that the import-
ers have been unreasonably tantalized by the course that the
Commissioners and the Health Officer of the Port have seen fit
to pursue. This we say without any reference to the charges
that these officials have played into the hands of a particular
company holding the patent of a disinfecting process. We are
not surprised to learn, therefore, that the importers have at last
shown a disposition to take the matter to the courts for adjudi-
cation. We sincerely trust that the outcome of the contention
will be to block the game of those who seem to be seeking to
still further handicap a port that nothing but the most bountiful
provisions of Nature could have saved thus far from the rapaci-
ty of the politicians.
THE DANGER OF SMALL-POX FROM CANADA.
We can scarcely overlook the magnitude and the pressing
urgency of the danger of the Canadian ontbreak of small-pox
gaining access to our own territory. Much will depend upon
the vigilance and the intelligence displayed at a few important
points, particularly Buffalo. Wo are glad to learn, therefore,
that the sanitary officials of that city seem fully alive to the
exigency, and that their efforts are meeting with hearty co-
operation at the hands of the Canadian authorities. We re-
member that Buffalo was one of the best-managed places in the
great epidemic of 1872-1873, and we have no doubt that its
citizens may be depended upon to call into play, if necessary,
the individuals and the machinery that served so well at that
time.
A NEW MEDICAL JOURNAL IN BUFFALO.
We have received the first number of a new monthly jour-
nal, entitled ''The Medical Press of Western New York," pub-
lished in Buffalo. It is edited by Dr. Roswell Park, of Buffalo,
assisted by Dr. M. D. Mann, of Buffalo, Dr. Ely Van de War-
ker, of Syracuse, and Dr. W. J. Herriman, of Rochester. These
gentlemen make a very strong staff, and we look to see the
new journal take a very high position. Of the first number,
dated November, 1885, we can say that it augurs exceedingly
well.
A FLORIDA MEDICAL JOURNAL.
It is announced that the first number of a monthly journal
of sixty pages, to be styled the " Florida Medical and Surgical
Journal," will be published at Jacksonville on the 1st of Novem-
ber. It is to be edited by Dr. T. O. Summers, Dr. C. H. Mal-
lett, and Dr. Neal Mitchell, who promise that no efforts will be
spared to make it " a faithful exponent of the highest interests
of the profession throughout the State." A feature of the jour-
nal, and one that can be made very valuable, is to be the sup-
plying of information concerning the influence of the Peninsular
climate.
NEWS ITEMS, ETC.
The American Academy of Medicine will hold its next
meeting in New York on Wednesday and Thursday', the 28th
and 29th inst.
The New York State Medical Association will hold its
second annual meeting in New York on Tuesday, Wednesday,
Thursday, and Friday, November 17th, 18th, 19th, and 20th.
The last day's session will be held at the Carnegie Laboratory,
and the others at the Murray Hill Hotel.
The Medico-Chirurgical College of Philadelphia.— We
learn that Dr. Frank Woodbury, the editor of the "Medical
Times," of Philadelphia, has been appointed professor of materia
medica and therapeutics.
The Journal of the American Medical Association.— Dr.
William Lee, who, from the beginning, has been assistant edit-
or of the association "Journal," has, we understand, been dis-
missed by the editor. Dr. Lee was appointed by the original
committee a member of the council of the Section in Physiology
of the Ninth International Medical Congress, but resigned after
the Chicago meeting of the New Orleans committee.
The British Gynaecological Society.— Dr. Fordyce Barker,
Dr. T. Gaillard Thomas, and Dr. Thomas Addis Emmet, of New
York, and Dr. William Goodell, of Philadelphia, have been
elected honorary fellows.
Cremation was the subject of an interesting paper, by Dr.
William M. McLaury, read before the Society of Medical Juris-
prudence and State Medicine on Thursday evening of last week.
The Preventive Inoculation of Hydrophobia.— A recent
issue of "Science" contains an extract from a letter lately
written by M. Pasteur, in which he expresses his confidence in
his method of preventing hydrophobia, even when applied so
late as a fortnight aftor the bite. As yet, he has made only one
trial of it on the human subject — in the case of a boy who had
440
been bitten horribly on the 4tli of last July, and whose death
by hydrophobia seemed unavoidable, but who, up to the time
the letter was written, September 7th, had continued in excel-
lent health.
The Marine-Hospital Bureau's Health Reports, up to
Tuesday, the 13th, show that yellow fever is epidemic in Cara-
cas, and has appeared at Acapulco ; that the cholera in Spain is
abating, and has wholly disappeared in Valencia; and that
small-pox is raging in Buenos Ayres.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from October 4 to October 10, 1885:
Weisel, Daniel, Captain and Assistant Surgeon. To be relieved
from duty at camp at Rock Springs, Wyoming, and return
to his proper station, Fort Fred. Steele, Wyoming. S. O.
99, Department of the Platte, October 1, 1885.
Adair, George W., Captain and Assistant Surgeon. Leave of
absence extended one month. S. O. 232, A. G. O., October
9, 1885.
Biart, Victor, Captain and Assistant Surgeon. Sick leave of
absence further extended six months on surgeon's certificate
of disability. S. O. 227, A. G. 0., October 3, 1885.
Busitnell, G. E., First Lieutenant and Assistant Surgeon. Grant-
ed leave of absence for one month. S. O. 215, Department
of the East, October 6, 1885.
Stephenson, William, First Lieutenant and Assistant Surgeon.
Relieved from duty at Fort Niobrara, Nebraska, and ordered
for duty at camp at Rock Springs, Wyoming. S. 0. 99, De-
partment of the Platte, October 1, 1885.
Chapin, A. R., First Lieutenant and Assistant Surgeon. Leave
of absence extended one month. S. O. 230, A. G. 0., Octo-
ber 7, 1885.
Naval Intelligence. — Official List of Changes in the Medi-
cal Corps of the United States Navy for the weeTc ending October
10, 1885.
Bright, George A., Surgeon. Ordered to TJ. S. S. Brooklyn.
Fitts, Henry B., Assistant Surgeon. Ordered to Naval Hospi-
tal, New York.
Hall, John H, Passed Assistant Surgeon. Detached from Na-
val Hospital, Mare Island, California, and ordered to the
Hartford.
Swan, Robert, Passed Assistant Surgeon. Detached from Na-
val Hospital, New York, and ordered to the Brooklyn.
Society Meetings for the Coming Week:
Monday, October 19th: New York County Medical Associa-
tion ; Medico-Chirurgical Society of German Physicians ;
Hartford, Conn., City Medical Association ; Chicago Medical
Society.
Tuesday, October 20th : New York Academy of Medicine (sec-
tion in Theory and Practice of Medicine); New York Ob-
stetrical Society (private) ; Medical Societies of the Counties
of Kings and Westchester (White Plains), N. Y. ; Medical
Society of Hunterdon County (Flemington), N. J. ; Ogdens-
burg, N. Y., Medical Association.
Wkhnesday, October 21st: Northwestern Medical and Surgical
Society of New York (private) ; New Jersey Academy of
Medicine (Newark) ; Philadelphia County Medical Society
(clinico-pathological).
Thursday, October 22d : New York Academy of Medicine (sec-
tion in Obstetrics and Diseases of Women and Children) ;
Harlem Medical Association of the City of New York ; New
York Orthopaadic Society ; Roxbury, Mass., Society for.
[N. Y. Med. Jour.,
Medical Improvement (private) ; Brooklyn Pathological So-
ciety ; Pathological Society of Philadelphia.
Friday, October 23d: Yorkville Medical Association (private);
New York Society of German Physicians ; New York Clini-
cal Society (private) ; Philadelphia Clinical Society; Phila-
delphia Laryngological Society.
Saturday, October 24th : New York Medical and Surgical So-
ciety.
f titers to % Winter.
THE NEW YORK CODE OF ETHICS.
Newark, Ohio.
To the Editor of the New York Medical Journal :
Sir : Dr. Jacobi's remarks, in his able address in your issue
of October 3d, on the International Congress, will not fail to
find a sympathetic echo in the heart of every true physician ;
but, in common with others, I can not help an exclamation of
surprise at what he says on the war of the codes, or of the
" unexpected success on the part of the profession of the State
of New York in harmonizing a large majority of the medical
men of the United States." What his grounds are for this as-
sertion, I have only his own inadequate explanation, which is,
at least in part, grounded on a misapprehension, and one, too,
that is fundamental, so far as the issue is concerned between the
New York and the national codes of ethics. He says that
homoeopathists now maintain that "their practice is not based
on an exclusive dogmn." If the adherents to that ism in New
York have progressed that far, they are to be congratulated,
and it is to be hoped that this advance will soon be followed
by another — to discard the trade-mark of their sect. Now, Dr.
Jacobi seems to take it as a matter of course that the liberaliza-
tion of homoeopathy in his State warrants the conclusion that
it has extended to all the States. In other words, as goes New
York so goes the whole country — a somewhat exaggerated form
of cockneyism. During a long and not very limited acquaint-
ance with homoeopaths in this region, I have only found one of
the kind he mentions, and he is a half-breed.
Put this question to homoeopathic practitioners — not to be
answered by some spread-eagle orator in a public assembly, but
by the working men with whom we are brought into daily re-
lations— Are you willing in consultations to use large or small
doses of medicines, to order purgatives or emetics, or to employ
the lancet, if the large majority of the most eminent physicians
the world over testify strongly in their favor in appropriate
cases? The homoeopath instantly replies, No, if by a majority
of eminent medical men you mean allopaths. Now, I venture
to assert that this would be the reply of ninety per cent, of the
homoeopaths with whom we in this region are brought into con-
tact. The New York code says : You may meet such men in
consultation. What for? To try to reconcile irreconcilable
differences; to argue and get into unseemly quarrels in the sick-
room ; or with oily suavity yield up your convictions of what
will most likely save life, for the sake of a fee? The homoeo-
path, in such an instance, would be by far the more honorable
of the two. I say emphatically that in this region the regular
physician who meets a homoeopath in consultation must do one
or the other of these things, and the New York code of honor
says lie may. Away with such a consent to a course of con-
duct that must lower the morale of the profession, and, when
I say this, I am confident that I have at least ninety per cent, of
the profession at my back. J. R. Black.
LETTERS TO THE EDITOR.
Oct. 17, I8b5.]
PROCEEDINGS OF SOCIETIES.
441
PRIZE ESSAYS ON DISINFECTANTS.
199 Dean Street, Brooklyn, N. Y., October 5, 1885.
To the Editor of the New York Medical Journal :
Sir: I desire to call the attention of the profession to a fla-
grant exhibition of what must either be favoritism, ignorance,
or a culpable disregard of all justice. I allude to the decision of
the prize committee appointed by the publisher of the " Drug-
gists' Circular " for the proper awarding of three graded prizes
to the best three essays on disinfectants. All competing essays
have been printed in a neat volume of 1G8 pages. The first
prize was awarded to essay No. 6, written by a non-medical
man, and a former editor, I believe, of the paper offering the
prizes. His essay is a heterogeneous rehash of old and new
opinions and recommendations on disinfectants and antiseptics.
He seems to have succeeded in impressing the committee by his
long array of references, many of which are useless and unsci-
entific. The second and third prizes were awarded to two
physicians, and both their essays were worthy, in fact the only
such in the collection. The rest of the work is composed mainly
of trash. Essay No. 21 covers but one page. I am astounded
at the committee's decision, as Dr. Baker, of Lansing, Mich,
was one of the examiners. No. 6 is thoroughly unscientific,
and fails to agree with the terms upon which the award was
promised to be made. That such a decision is not without gross
risks is apparent when we consider that the druggists, to whom
the people go for disinfectants, rely upon the judgment of the
awarding committee as to which is the best essay, and by this
they will be guided. Since the public are in this way at the
mercy of the druggists, I have written you in the hope that
others may be directed to this matter, and that such able au-
thorities as Dr. Sternberg, Dr. Salmon, Dr. Duggan, and others
■will set upon it the seal of their condemnation. The two essays
that received the lower prizes have the merit of being up to the
times and giving sound sanitary advice. Could the pharmacists
be taught to prepare their disinfectants of the materials these two
advise, much good certainly would be done, and many lives saved.
The first-prize essay is so poor, compared to the other two, that
it can not be compared with them. It is a shallow, hurried,
carelessly written compilation. I do not see that the writer
deserves any blame — he is a layman, and can not know as much
about the subject as an intelligent physician. I do think,
though, that the committee deserves everlasting discredit for
the work it has done, and I regret that its work is stamped
with the seal of Dr. Baker's approval. Trusting that this will
be "passed along," I have the honor to be,
Very respectfully yours,
A. H. P. Leuf.
Jlroceeinngs of Sotittus.
MEDICAL SOCIETY OF THE COUNTY OF NEW YORK.
Meeting of September 28, 1885.
The President, Dr. Daniel Lewis, in the Chair.
Nominations were made as follows: For President, Daniel
Lewis ; for Vice-President, Laurence Johnson ; for Secretary,
Wesley M. Carpenter; for Assistant Secretary, Charles II. Avery
and Robert Campbell; for Treasurer, O. B. Douglas; for Cen-
sors (five to be elected), II. T. Peirce, W. E. Bullard, W. O.
Moore, II. B. Conrad, W. Wells, II. G. Piffard, and J. W.
Howe.
Gonorrhoea in Women. — Dr. A. F. Currier read a paper
with this title. [See p. 424. J
Dr. H. T. Hanks regarded the question of the aetiology of
gonorrhoea as still undecided, but the pathological results of the
disease and the indications for treatment were not doubtful.
He believed with Dr. Currier that a very large percentage of all
diseases peculiar to women were due to gonorrhoea. In dispen-
sary practice one would see patients who had had acute gonor-
rhoea return some years afterward suffering from troubles which
had their origin in such acute inflammation. He did not believe
that any physician, without the aid of the microscope, could
make a sufficiently accurate diagnosis of gonorrhoea. But, as to
the pathological results of acute gonorrhoeal inflammation, he
thought we should feel more confidence in our ability to treat
them successfully. He would beg leave to differ with Dr. Cur-
rier with regard to the relative frequency of gonorrhoeal endo-
metritis and urethritis. He regarded the latter affection as far
the more frequent. If the circum-uterine tissues, the Fallopian
tubes, and ovaries became affected, we could do much by judi-
cious treatment — as by applications of iodine, glycerin, chlorate
of potassium, etc. In the treatment of the disease in its acute
stage, he agreed with the author of the paper in the use of
vaginal injections of chlorate of potassium, or carbolic acid,
corrosive sublimate, etc. The treatment should be systematic,
the injections being made every four hours.
Dr. H. J. Garrigtjes had not looked for gonococci, but had
been enabled to make the diagnosis between simple elytritis and
gonorrhoea by the more virulent symptoms of the latter. He
often found Bartholin's glands affected, and found it necessary
to open them and make applications. The most effectual vagi-
nal injection for the acute disease was a solution of bichloride
of mercury, one to two thousand; but other agents had also
proved efficacious in his hands. As to the involvement of the
urethra, he agreed with Dr. Currier that it was not often pres-
ent. For the disease in the uterus he applied Churchill's
tincture of iodine. As to the efficiency of medicated pads, he
thought the glycerin was probably the efficient agent rather
than the medicine which it contained.
Dr. H. J. Boldt thought urethritis was more common than
the remarks of the gentlemen would lead us to suppose. The
majority of cases of acute gonorrhoea would not end in less than
three months.
Dr. Lyttle said it had been stated that we must depend
upon the clinical phenomena in making a diagnosis; he failed to
see, therefore, the value of the gonococcus. The treatment was
the same as that which had been adopted before the discovery
of that microbe.
Dr. Messenger had never seen a patient upon whom lie could
rely for making proper vaginal injections; the physician should
carry out the treatment himself, and make the injections thor-
ough. The syringe which he used was described as being spe-
cially valuable in enabling one to fully balloon the vagina with
the bichloride solution.
Dr. Currier closed the discussion, and said he was not sure
that glycerin did not play an important part in the treatment
when it was employed as a vehicle for other medicines. The
value of the gonococcus in diagnosis would be specially seen in
cases brought into the courts.
The Treatment of Leprosy.— Dr. G. H. Fox read a paper
on this subject, in which he deprecated the tendency to depress
the patient morally by giving him to understand that his disease
was incurable, and by making him an outcast from society or
confining him with those affected in like manner. The patient's
morale was of far greater importance than change of climate,
attention to food, etc. — conditions which were considered neces-
sary to his welfare. He gave the history of a missionary to the
•
442
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Joub.,
Sandwich Islands who contracted leprosy. The symptoms had
become well marked, but he was given to understand that his
case was not hopeless and that he should not be put under re-
straint, and chaulmoogra-oil was given. He steadily improved,
and at present there remained only some symptoms in the hands.
Leprosy was only moderately contagious, and the author knew
of no instance of its gaining a foothold in a refined community ;
he therefore regarded confinement as unnecessary.
Dr. Fuller had seen several hundred lepers at Havana, and
said the disease was regarded as contagious, but only slightly,
and they were not very strictly confined.
Dr. Moore had been in the West Indies, and could testify to
the buoyancy of feeling among the lepers there. He did not
think that want of sympathy or mental depression had anything
to do in preventing a cure. It was well known that there ofteD
occurred intervals when the disease was not progressive. There
were instances in which it 'had been known to be inherited,
although it might pass over a generation or more.
Dr. J. C. Peters had seen persons suffering from leprosy in
Havana, and they were generally indifferent to their condition.
Dr. D. B. Delavan had visited the institution for lepers in
Norway, where there were now only about seventeen hundred,
the number having been reduced from over three thousand.
They usually came from among the lowest classes. They were
not under very great restrictions. He expressed surprise at the
position taken by the author of the paper, but he would be glad
if his views regarding the curability of the disease might he ful-
filled.
Dr. Piffard said that where many patients suffering from
leprosy were found the treatment was practically nil. The
few patients whom he had treated had improved under the use
of nux vomica and chaulmoogra-oil. The system became intoler-
ant to one drug if taken for some time, and the two should,
therefore, be alternated.
NEW YORK PATHOLOGICAL SOCIETY.
Meeting of September 23, 1885.
The President, Dr. John A. Wteth, in the Chair.
Recurrent Epithelioma of the Penis.— Dr. W. Perry
Watson showed a portion of a penis and the patient from
whom it had been removed, a laboring man, forty-nine years
of age, of good family history, and without any history of spe-
cific disease. His health had always been good. Phimosis
had existed, which caused marked "ballooning" of the foreskin
during urination. In 1865, while he was sitting at table, a fork
was thrown at him, and one tine pierced the dorsum of the glans
penis. There was considerable bleeding, but a physician was
not called. Soon afterward he was admitted into Bellevue Hos-
pital, where, according to his statement, Dr. Hamilton ampu-
tated a portion of the foreskin which was said to be indurated.
No portion of the head of the penis was removed. The speaker
thought it probable that the induration referred to by the pa-
tient was a blood-clot. He had no further trouble for about six
months, when a wart-like growth developed near the fraenum.
This grew, and, being constantly irritated, was removed six
months later. Six months afterward an ulcerative process set
in at the base of the wart-like growth, which increased in di-
mensions, and for a year before the speaker saw the patient,
which was two years ago, gave rise to considerable hemorrhage.
Dr. Watson advised amputation, and the circular operation was
done, the urethra being slit up and stitched to the skin. The
man had been well since, no tendency to a return of the disease
being manifest. The inguinal glands had at no time been en-
larged. The epitroehlear glands were slightly enlarged.
The President had seen four cases of epithelioma of the
penis during the past eighteen months, in three of which he
had performed amputation, and in all there had been phimosis.
He had conversed with several surgeons on the subject, and
had not heard of a single case of carcinoma of the penis in
which there had not been phimosis. This was certainly one
other indication for circumcision.
A Vermiform Appendix of Unusual Length and At-
tachment.— Dr. Louis Waldstein presented a vermiform ap-
pendix 10 ctm. long, which he foimd in a cadaver at the Ger-
man Hospital. It reached upward to the hepatic flexure of the
colon, to which it was attached. Probably there had been
slight local peritonitis and displacement of the colon downward,
during which the adhesion was formed. The colon afterward
resumed its normal position, carrying the appendix with it.
Biliary and Renal Calculi— Dr. Waldstein also presented
a urinary calculus, composed of urates, which was interesting
in connection with the history. Mr. S. sent for him in April
last, suffering from pain in the abdomen, the greatest tender-
ness on pressure being over and just to the right of the epi-
gastrium. The pain radiated over the entire abdomen. There
was slight icterus of the conjunctive and integument. The
diagnosis of biliary calculus was made. The patient improved
under the use of Carlsbad water. Large numbers of concre-
tions were found in the fasces. Subsequently the speaker was
called to visit the patient for an attack of pain which com-
menced in the right lumbar region, extended downward along
the course of the ureter and right thigh, and was diffused over
the abdomen. The patieut said that when micturating he had
a peculiar sensation at the glans penis and a tingling of the
fingers of both hands, also some dizziness, and occasionally saw
movches volantes. The diagnosis of urinary calculus was made,
and subsequently was confirmed by the passage of the calculus
presented. An interesting fact in the case was that during
eleven or twelve years the patient had had digestive derange-
ment, and finally, as was apt to occnr, biliary calculi developed,
and also renal calculi.
The President referred to a largely distended vermiform
appendix which he had seen while in Bellevue Hospital, but he
had never seen one so long as that presented by Dr. Waldstein.
MEDICAL SOCIETY OF VIRGINIA.
Sixteenth Annual Meeting, held at Alleghany Spirings, Tuesday,
Wednesday, and Thursday, September 15, 16, and 17, 1885.
Dr. Bedford Brown in the Chair.
( Concluded from page 419.)
Dyspepsia with Neurasthenia and Somnolence.— Dr. M.
L. James, of Richmond, read a paper on this subject. He re-
ferred to the fact that, although this morbid association was a
serious inconvenience, and sometimes a grave disability, it had
not in this particular association received very much of atten-
tion in the books. While it very often resulted from the ex-
cesses of dissipation in the various forms, it was yet more fre-
quent in the best types of manhood and womanhood, those
whose only intemperance was excessive thought and exhausting
labors of love, and for that reason especially commended itself
to the consideration of men of science and physicians from
kindred sympathies. He referred to the fact that indigestion
was one of the most frequent causes of neurasthenia, from its
combined influences in impairing nutrition and producing a cer-
tain species of shock on the nervous system, and that in its
treatment it should be remembered that these morbid conditions
reacted upon each other. While dyspepsia produced neuras-
thenia, neurasthenia, on the other hand, was liable greatly to
intensify dyspepsia.
Oct. 17, 1885.]
PROCEEDINGS
OF SOCIETIES.
443
lie indicated- that the judicious treatment of this condition
demanded what might be described as training, in which the
correction of each of these conditions might be made to con-
tribute to the relief of the morbid condition in the other ; that
digestion was better performed by securing the utmost integrity
of the innervating forces, and the asthenia of the nervous
forces was greatly diminished by removing the disorders of
digestion. For that reason he emphasized the importance of
securing to the patient an ample amount of undisturbed sleep,
to commence the labors of each successive day, and then that
the food should be selected with a view to its ease of digestion
and its capacity to afford nutrition to the nervous tissues. A
period of rest in the recumbent position, accompanied by sleep
from a half-hour to two hours previous to dinner (after which
the greatest amount of difficulty was usually experienced), was
attended by the best results.
In the matter of medication, while he spoke of the good
effect of a judicious use of stimulants, especially such as stimu-
lated the cerebral lobes and averted sleep, such as was found in
coffee or its alkaloid, cafl'eine, that for permanent restoration
those agents which were more decidedly tonic, such as quinine,
strychnine, and phosphorus, or its compounds, or such agents in
combination with minute quantities of caffeine, were best calcu-
lated to afford remedial benefit. He mentioned the following
as one of the formulae which he had been accustomed to use
with the most efficient results:
R Quininae phosphat., gr. xvj ;
Strychninae phosphat., gr. \\
Acidi phosphorici (50 per cent.), ttixx;
Caffein. citrat., gr. xvj;
Aquae purse, f 3 vij ;
Glycerini puri,
Spts. vini rectif., aa f § ss. ;
Tr. cardamomi co., f 3 j.
Misc. secundum artem.
One or two teaspoonfuls immediately before or after break-
fast or dinner, to be repeated, when necessary, every hour or
two till the nervous depression was relieved, or every half-hour
till one or two doses were taken if this depression was heavy.
He stated that where digestion was impaired to that degree
that food in the ordinary form was not tolerated and digested,
he advocated the use of concentrated animal preparations in a
fluid form, and of foods predigested by the use of pepsin and
pancreatin; and where this amount of difficulty was so ex-
treme that they could not be administered b.y the stomach they
ought to be administered through the rectum.
Report on Advances in Hygiene and Public Health.—
Dr. Edwards announced the sudden death of the Eeporter, Dr.
William H. Ooggeshall, of Richmond, on September 7th — just
after he had finished his paper. By unanimous vote, Dr. Ed-
wards read the paper, the title of which was':
The Recent Plymouth, Pa., Epidemic and the Lessons it
teaches. — A full account of the epidemic was given and deduc-
tions were made, based upon an analysis of its history.
Inhumation and Cremation was the title of a paper by Dr.
J. E. Chancellor, who spoke of the principal methods of dis-
posing of the dead. The major portion of the paper was de-
voted to the subject of inhumation and its evils, many authori-
ties being cited, and the testimony of scientists and medical men
of the East who had made it a subject of close investigation.
Report on Ophthalmology and Otology.— Dr. Phillip
Taylor, of Richmond, read a paper in which mention was
made of the practical benefits to be derived from the use of
jequirity in trachoma with or without pannus. He insisted
upon the fact that chronic purulent conjunctivitis should not be
present when jequirity was used. The late theory relative to
the transmission of sympathetic ophthalmia — viz., by means of
the inter-vaginal lymph-spaces of the optic nerve— was given,
and conclusions concerning septic poison being conveyed by the
ciliary nerves from the diseased or injured eye to the unimpaired
organ — the once popular theory — were rendered. Cocaine re-
ceived notice as one of the most important strides that had been
made in ophthalmology for many years. Its uses and effects
were dilated upon. Numerous operations were referred to that
had been brought before the profession during the past year,
notably one for pterygium by Dr. Prince, of Illinois, another for
evisceration of the eyeball as a substitute for enucleation, also
one for the transplantation of the cornea. He referred to the
danger of performing the operation for internal strabismus in
the young and making the correction absolute, and pointed out
the fact that, as maturity came on, insufficiency was quite apt
to follow, causing external squint.
In otology, some recent preparations for purulent ear troubles
were discussed, especially peroxide of hydrogen. New-style Eu-
stachian catheters and the method of using bougies for dilating
the Eustachian tube were approved. The connection between
diseases of the teeth and those of the ear was referred to, and
statistics were rendered showing that sympathy existed between
these parts.
Practical Remarks and Suggestions in regard to Dis-
eases of the Ear, Throat, and Nose, with Reports of a Few
Cases. — Dr. Joseph A. White, of Richmond, presented a paper
on this subject. In speaking of the disastrous consequences of
neglected middle-ear catarrh, he remarked that neglected sup-
purative inflammation had resulted fatally. Pain should he
overcome by local leeching, warm applications, the use of
twenty-per-cent. solution of cocaine hydrochlorate with atropine
in the ear, and anodynes internally. Cocaine did anaesthetize
the drum-membrane. Pilocarpine hydrochlorate and calcium
sulphide should be administered during the exudative stage, but
caution should be exercised in using pilocarpine during the
aural troubles following any of the exanthemata lest the heart
be paralyzed. If pain persisted and the drum head bulged, the
posterior-inferior quadrant should he opened, and, by aid of the
air-bag, the tympanum evacuated. Then the ear should be
gently and frequently syringed with carbolated or borated solu-
tions of sodium bicarbonate, and the Eustachian tube kept free
by the daily use of Politzer's air-bag. If pain continued, the co-
caine solutions should be continued, but the atropine left off, as
the latter was dangerous when the drum-head was opened.
Powdered boric acid might also be dusted over the drum once
or twice a day. Mastoid and diseases of the brain often oc-
curred from neglected middle-ear complaints; permanent deaf-
ness was common. Especially during the course of scarlet
fever, the earliest signs of ear trouble should receive close at-
tention. Leeching and the use of calcium sulphide would often
avert threatening mastoid complications. If there was redness
or pain on pressure over the mastoid process, freely incise to
the bone, and even trephine the bone if pain continued.
Dr. White next referred to the influence of menstruation at
puberty and at the menopause upon ear diseases. Impaired
hearing due to adhesive middle-ear catarrh was very common
about the climacteric period. He cited the case of otorrhoea
which began at puberty and yielded readily to treatment, but
recurred at each menstrual period until finally the menstrual
irregularity was relieved, when the otorrhoea also ceased.
As to syringing the ear, be careful, he said, not to use too
much force in removing impacted wax, foreign bodies, etc.
Dizziness, syncope, violent pain, followed by suppurative in-
flammation and deafness, had resulted from too forcible syring-
ing. To remove impacted wax, first partially dissolve it by
4U
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Joce.,
frequent applications of warm solutions of sodium bicarbonate in
glycerin and water, and then very gentle syringing would re-
move the mass. When required to loosen a lump of wax or
such a thing with forceps or probe, we should not attempt to
do it without good illumination from a head-mirror.
Follicular amygdalitis and catarrhal diphtheria were often
confounded. In diphtheria, in addition to the fever, occasional
nausea, pain in the throat which generally began on the third
day, and patchy exudation on the swollen tonsil, as we had in
follicular amygdalitis, the exudation extended over the mucous
membrane of adjacent structures. Guaiacum acted almost as a
specific in follicular amygdalitis, which supported the belief that
rheumatics were most liable to it. If recurrent attacks became
common, or if the tonsil became so hypertrophied as to affect
nasal respiration or impair articulation, he advised the removal
of the enlarged tonsil. The only risk was haemorrhage, and
that usually was but slight. The rule should be to remove any-
thing that interfered with nose-breathing or rendered mouth-
breathing necessary. Interference with nasal breathing caused
deafness, tinnitus aurium, etc., and the reflex phenomena, such
as reflex cough, sick headache, asthma, and hay fever. The
paper concluded with reports of two typical cases of hay fever
cured by the use of the galvano-cautery applied to the sensitive
points of the nasal mucous membrane.
Two Cases of Tracheotomy — One for Lupus of the
Larynx, and One for Diphtheria— were reported by Dr.
Charles M. Shields, of Richmond. He had found mention in
the text-books of about a dozen cases only. The case now re-
ported was that of a retired doctor, about fifty-five years old.
He had had hoarseness and pain while swallowing for more
than a year. Now he could speak only in a hoarse whisper,
and he had dyspnoea. The laryngoscope revealed general red-
ness and congestion, with so much swelling of the right vocal
cord and ventricular band as to make them indistinguishable.
This growth was covered with small, pale, fleshy tubercles, hav-
ing superficial ulcerations between them. The patient never
had syphilis, nor were there any signs of phthisis, nor was
cancer hereditary in the family. These usual causes of laryngeal
growths were therefore excluded. The diagnosis of lupus was
strengthened by the appearance of two or three small, suspi-
cious ulcerated growths upon his face and arm which would not
heal until excised, and which were probably skin manifestations.
At first he took iodide of potassium, and afterward arsenic,
and, locally, iodoform and bismuth ; but the lupus progressed
until seven months after the patient presented himself, when
the ulceration and swelling occluded the larynx. Both sides of
the larynx were immensely swollen and covered with the pale
elevations and ulcerations, and no glottic aperture could be
seen. Tracheotomy was performed without chloroform, but it
was a tedious operation because of his short, thick neck and
the pushing down of the trachea by the enlarged larynx, leav-
ing very little space for the incision ; an unusually long cannula
had to be used. Great relief followed the operation, and he soon
learned to remove, clean, and replace the entire tube without
difficulty. He was doing well during the next summer.
Dr. Shields also reported a successful tracheotomy for laryn-
geal diphtheria in a child three years old. After the fifth day
the membrane in the larynx increased so rapidly as to threaten
death by suffocation. Iron, quinine, and large quantities had
been used. Vapor of lime filled the room. Tracheotomy was
not consented to by the parents until the sternum was drawn
in and the patient was cyanosed and thought to be dying.
The tracheotomy-tube was introduced as soon as the incision
was made, but all appearance of breathing stopped. Artificial
respiration was kept up and the tube withdrawn again, when,
with forceps, a membrane, cast upon the trachea, two inches
long, was removed. The cannula was again put back, and, arti-
ficial respiration being continued, the child finally began to
breathe. She did well for two days, when difficult breathing
set in, and she coughed up through the trachea another cast.
Diphtheritic membrane covered the edges of the wound. No
air passed through the larynx for nearly a week, and the tube
had to be kept in for three weeks before she could breathe com-
fortably through the natural channel. She made a good recov-
ery. *
Infanticide was the title of a paper forwarded by Dr.
Charles R. Cullen, of Henrico County, who was unable to
attend. The writer did not follow the usual routine found in
the text-books on medico-legal jurisprudence, but merely sought
to direct attention to the weakness of Virginia laws on the sub-
ject. Dr. William H. Taylor, Coroner of Richmond City for
about thirteen years, furnished statistics of 139 persons tried for
infanticide during his term of office — 43 whites and 9G negroes.
Of the total number, not a conviction followed. The laws of
England and Scotland had succeeded better. Of 68 trials for
infanticide in London, 53 convictions followed. In New York
and Pennsylvania the laws were much more certain of securing
convictions than in Virginia. The very harshness of the Vir-
ginia laws caused them to fail of good results. Dr. Cullen re-
ported two cases of trials for infanticides which had come under
his attention, showing the weakness of the Virginia laws, and
he called on the society to aid in reframing the State laws re-
lating to infanticide.
A Plea for Tracheotomy in Croup. — A volunteer paper
with this title was read by Dr. L. Ashton, of Falmouth.
He said that the good that was to result from the timely per-
formance of tracheotomy was so great that it should be placed
among the minor surgical operations. This classification would
materially help to popularize it and take from it that dread
that parents so often felt regarding it. The operation in itself
was comparatively free from danger, but was a delicate one,
requiring coolness and caution, and, when performed hurriedly,
was too often made difficult and dangerous. The operation not
being dangerous in itself, nothing connected with its mere per-
formance should influence the time when it was to be resorted
to. As soon, he said, as it was decided that a positive mechani-
cal obstruction to the entrance of air into the lungs existed, the
operation should be done, before such secondary complications
as broncho-pneumonia, oedema of the lungs, prostration of nerv-
ous energy, etc., occurred. In the majority of cases of croup
death resulted from want of oyxgen in the blood. It should be
performed in all cases where the croup was progressive and un-
affected by medical treatment. In a number of cases the extension
of croup was arrested by tracheotomy. The admission of air into
the lungs through an artificial opening in the windpipe secured
entire rest for the diseased larynx, and this led to a suspension
of diseased action there. The diphtheritic process, clinically
speaking, stopped at the level of the vocal cords much oftener
than was commonly supposed. When the disease involved the
trachea, it was by propagation from the larynx, and not by a
simultaneous attack on the larynx, trachea, and bronchi ; and
this extension downward was generally prevented by early
tracheotomy. Since the operation alleviated suffering, miti-
gated the symptoms, obviated secondary complications, and did
not add one element of danger to the original disease, there
ought to be no delay in its performance. Many children had
even been brought to life again by it, with the aid of artificial
respiration.
Psychological Aspects of Suicide. — During the night ses-
sion Dr. J. S. Conrad, Superintendent of Matley Hill Sanita-
rium, near Baltimore, Md., by invitation read a paper on this
' subject, and made the following conclusions:
Oct. 17, 1885.]
MISCELLANY.
445
1. Suicide increased with the advance of civilization, and
was but little known in the savage state of men.
2. The act was an intelligent act (?), done with a full con-
sciousness of the act, as shown by the method of execution,
whether by the sane or insane.
3. That suicide was done always for the purpose of escaping
an evil, and for the benefit of the felo-de-se, whether by sane or
insane.
4. That it was a voluntary act (?), whether by sane or in-
sane.
5. That it was an emotional act, whether by sane or insane,
however deliberately planned and executed, since deliberation
entered into the mind of both mental states.
6. That delusions were not essential to the distinction as
to the sanity or insanity of the suicide, since authorities af-
firmed that delusions were not essential to the proof of in-
sanity.
7. That suicide was rare in the first class — -insanity (by
Maudsley), viz., intellectual or ideational insanity — but did occur
in the vast majority of the second class, or affective or emotional
forms of insanity.
8. Query : Was suicide an intellectual act notwithstanding
the intelligence exercised in its execution ? Or was it an emo-
tional act per se, since we had seen that the emotional part of
mind dominated the ideational centers and perverted the intel-
lect into becoming its humble servant?
9. Did moral depravity satisfactorily account for it, when
we had seen that moral depravity was a factor with both the
sane and the insane ?
10. That, in doubtful cases of the sanity or insanity of the
felo-de-se, very great caution was necessary in making up a just
judgment as to the one or the other.
Irritable Rectum. — Dr. Archer Atkinson, of Baltimore,
present by invitation, read a brief paper on this subject, in
which he called attention to the various causes for this condi-
tion. He also reported a case in which he ligated the artery
of a large bleeding hsemorrhoidal tumor.
Gunshot Wound of the Hand.— Dr. William G. Eggle-
ston, of Chicago, reported a case of this injury. C. H. G., a
physician, aged thirty-three years, received an extensive lacer-
ated wound of the left hand, in February, 1885, while attempt-
ing to remove the cap from a loaded shell. The cartridge
exploded, and the entire charge of shot, so far as was known,
passed through the hand. The resulting wound extended, on
the palmar side, from a point immediately anterior to the nor-
mal situation of the deep palmar arch, between the metacarpal
bones of the middle and third fingers, tearing the hand com-
pletely open, thence to the webbed junction of these fingers,
tearing the flesh from the first phalanx of the third finger, save
a small portion ou the dorsal aspect, and breaking the first
phalanx of this finger and the metacarpal bones of the third
and little fingers about the middle third.
The wound was thoroughly cleansed with hot water, the
clots were removed, flaxen sutures put in place, compresses ap-
plied over the palmar and dorsal wounds, and the whole meta-
carpal portion of the hand was bandaged rather tightly with
short bandages, so that they could be easily removed in case of
haemorrhage. The middle finger was used as a splint to the
broken third finger. Turpentine was then injected into the
wound, and the bandages were thoroughly soaked with it.
Subsequently a drainage-tube was put in, and a weak bichloride
solution used. On September 10th, seven months alter the re-
ceipt of the injury, the patient reported that the third finger
was practically useless, but that ho could do all ho wished with
the hand; the grip was good, "the stiff finger seldom getting in
the way."
P t s 1 1 II a n g .
The Report of the Meeting of the Committee on the Interna-
tional Medical Congress. — The " Medical News," of Philadelphia, pub-
lishes the following letter from Dr. R. A. Kinloch, of Charleston, S. C. :
" To the Editor of the Medical News :
"Sir: The following letter was addressed by me to the secretary
of the Committee on the International Medical Congress :
' Charleston, September 16, 1885.
' To Dr. John V. Shoemaker,
' Secretary of the Committee of Arranffeme?its for the
International Medical Congress.
' Dear Sir : In the " Journal of the American Medical Association "
for September 12th there is a publication, under your signature as
secretary, of what is styled a " Report of the Committee appointed to
arrange for the meeting of the International Medical Congress in Amer-
ica in 1887." As a member of the Committee of Arrangements, pres-
ent during the session of the committee held in New York city on the
3d and 4th of September, I am not aware that you were instructed or
authorized to make any other report than such a one as naturally per-
tained to your duties as secretary. The correct and full report of the
minutes of the meetings of the committee it is most surely your duty
to prepare, and the publication of such minutes, unless specially inter-
dieted by vote of the committee, seems to me to have been in order.
Your " report," as published, is not the minutes of the meeting, nor
does it fully or fairly represent these, as far, at least, as relates to the
meeting in New York. As a member of the committee I think it due
to the committee, and to the profession of our country, that the full
action of the committee, which carries with it the animus or real inten-
tion which determined its work, should see the light of day. You will
therefore pardon me if I appear intrusive when I ask you to inform
me if it is your intention to publish a detailed report of the minutes
of the late meeting of the committee, held in New York, on the 3d and
4th of September.
1 Very respectfully, R. A. Kinloch,
'Member of the Committee from South Carolina.''
"This letter was forwarded as far back as the 16th of September,
but lias failed to elicit a reply. I am, therefore, forced to conclude that
I shall not have the courtesy of a reply, and that there will appear no
official report of the minutes of the meetings of the Committee on the
International Congress, notwithstanding the interest manifested in this
matter by the profession. As a member of the committee, however
humble, I am not ashamed of any views I have expressed, or of any
action I have taken. Nor do I desire to bear the sins, either of omis-
sion or commission, or to claim the fruits of the good work that may
be the outcome of this body.
" I accepted a position on the enlarged committee created by the
action of the American Medical Association at its late meeting in New
Orleans, not because I approved of the action of the association in its
mode of dealing with the work of the original Committee of Eight, but
because I recognized the obligation to serve the association, and in-
dulged the hope of sustaining a spirit of harmony, which I feared
might be interrupted by the diversity of opinions coming of a too pon-
derous committee of arrangements.
" That the committee could best discuss the respective merits of
men suggested for filling important offices in the Congress by sitting
with closed doors, was an argument of some force ; but it will scarcely
be urged by scientific men that the shortcomings of the body, the con-
duct and ruling of its officers, the time of its discussions, the policy of
its actions, the views and the animus of its individual members, should
be guarded in the same way, and known only to unwritten history-
Why, then, I ask, this suppression of this much of the proceedings of
the meetings? And by what authority does the secretary of the body
undertake to report in the way that he has done '> As I was absent
from the meeting for a brief period prior to its adjournment, it is pos-
sible that the committee may have instructed the secretary as to his
446
MISCELLANY.
[N. Y. Mkd. JorH.,
course of action. If so, I can only at tbis late date raise my voice in
condemnation of such a policy.
" All the acts of the committee were of course the result of a ma-
jority vote, and, so far as it has worked for the supposed advantage of
the Congress, I prefer to say nothing. I trust that its action will prove
satisfactory. But, while majorities rule, minorities have certain rights,
and among these is the right to be put upon record. As an independ-
ent member of the committee, I do not intend that my rights shall
in all particulars be ignored. The verdict of a noble profession is
something that I hold of inestimable value ; the approval or disapproval
of a court so constituted I am willing to accept, provided such is based
upon my individual merits or demands. There was with me during all
my connection with the committee the proud desire to promote harmo-
nious action, and thus save the American Medical Association and the
profession of our common country from dissensions which threatened
their well-being, if not the vital interests of both, and which already
have, in part, subjected us to the censure, if not the ridicule, of our
foreign brethren.
" My first effort was at the informal meeting of the new members
of the committee at New Orleans, when I introduced the following reso-
lution, after there had been presented several propositions, all of which,
as seemed to me, were calculated to give some offense to the original
Committee of Eight.
" ' Resolved, That the temporary officers of this meeting be instruct-
ed to correspond with the original committee, expressing our desire to
meet them at such time and place as may be agreed upon by the ma-
jority of the entire committee.'
" The original committee had worked laboriously and deserved some-
thing of the association. If they had committed errors, they could not
escape criticism ; but with members of a common brotherhood, looking
to scientific progress, criticism need not give offense. No proper-feel-
ing brother desired to add to the mortification or irritation which natu-
rally attached to the members of the original committee, when there
were appointed additional members to their body, for the purpose of
reviewing their work. The object of my resolution then was to try at
the outset to establish friendly relations with the original body. The
new members were merely material added to this. The original com-
mittee was the fully organized body. It had not been abrogated, nor
was its organization changed by the recent action of the association.
A cautious word from the temporary officers elected by the new mem-
bers, if these officers were capable of appreciating the spirit of my
resolution, was really the first and surest way of harmonizing the new
with the old members of the committee.
" Dr. Flint and Dr. Billings were the officers of the Committee of
Eight. They were also, now, the officers of the enlarged committee,
until that committee should meet and decide to supplant them. It
rested, then, with these gentlemen to call the committee together ; the
duty pertained to none others.
" Some confusion arose in regard to the function of the committee
as enlarged, and as to the attitude of the original committee to the as-
sociation. The members of the original committee naturally desired
time for conference and careful conclusion. This should have been
accorded them. But, unfortunately, the temporary officers of the meet-
ing at New Orleans incorrectly estimated their position and failed to
perceive that harmony was necessary for professional unity, and unity
essential to the scientific interests of the Congress. The function of
these temporary officers had ceased after they had carried out the in-
structions given them by my resolution. And yet they magnified their
recent position, forgot the spirit of their instructions, ignored the ex-
istence of the president and secretary-general of the committee, trans-
ferred the headquarters of the committee from Washington to Phila-
delphia, called for the vote of all the members of the committee, as to
time and place of meeting, and resolved to meet at Chicago on the 24th
of June. Strange to say, it does not seem to have occurred at that
time to any of the members of the committee, besides myself, that
these temporary officers of the New Orleans meeting had committed a
bold and unjustifiable act. This was painfully evident to me, however,
for I saw at once that the letter and spirit of my resolution had been
trampled under foot, and I lost hope in the success of the Congress.
" The call for the Chicago meeting, made in the name, or under the
authority, of my resolution, seemed to be accepted by the committee as
right and proper. I alone protested and refused to vote. My protest
was sent to the 'Association Journal,' but reached the editor too late,
as he informed me, for the issue which immediately preceded the time
of meeting of the committee. As a final effort, I wrote an earnest let-
ter to Dr. Cole and Dr. Shoemaker, and insisted that my views should
be presented to the meeting in the event of my failing to be present.
The meeting was held at the time specified, but my letter or views were
not mentioned.
" The result of the Chicago meeting is known to the profession. I
was unavoidably absent, and subsequently shared only in the general
regret that the character of the work done necessitated its reconsidera-
tion. The meeting at New York was called partly for this purpose. I
was present, and at the earliest moment I claimed the privilege of hav-
ing recorded upon the minutes the letter which I had written to the
' Association Journal,' and which explained fully my views as to the
unjustifiable action of the temporary officers in calling the Chicago
meeting. I also made the public statement as to the failure of these
officers to bring my letter before the committee at Chicago. Through
the failure of the secretary to publish the minutes of the New York
meeting my views were again suppressed, and hence the unpleasant ne-
cessity of having now to justify my action. It is due to the officers of
the meeting to say that they disclaimed any intention of purposely sup-
pressing my letter at Chicago, but, at the same time, they offered no
very satisfactory reason for their singular omission.
" The next matter which duty to myself compels me to notice has
reference to the alteration of the rule, as adopted at Chicago, determin-
ing the American membership of the Congress. This rule had been
fixed, as was claimed, in obedience to the voice of the American Medical
Association, so as to restrict the membership on ethical grounds. The
determination of a few adroit members of the committee was now to
undo what had been done, and in their own peculiar way. By manage-
ment more suitable for a political than a professional or scientific body,
and which I will not now comment upon, the rule, as prepared for pre-
sentation to the committee, which it was claimed opened the Congress
to all members of the regular profession, was finally brought before the
body. I asked the gentleman who had introduced the subject whether,
under the proposed rule, all members of the Congress would be alike
eligible for office, and whether he would favor the election of any mem-
ber of the profession simply upon his merits, or whether there was not
a mental reservation upon the part of those suggesting the change by
which, upon ethical grounds, certain members would be members mere-
ly, and debarred from holding office.
" The answer came that in accordance with the ' resolution ' of the
American Medical Association certain parties must be refused high
position. I asked for the reading of the ' resolution ' referred to. 1
wanted to know whether the association had ever drawn any such fine
distinction, opening the membership to all, but restricting the distribu-
tion of honors. It turned out that there was no such resolution ever
adopted by the association. I then maintained that if the association
and its implied sentiment were to guide the committee upon this occa-
sion, it was more consistent to hold on to the Chicago rule than to
accept the amendment as now proposed. I offered to support the
amendment with all my heart if this was honestly offered, and if the
mover would amend it further by stating that all members were equally
eligible for office, or if he would agree to show that, practically, all
were eligible by voting for men on their merit and regardless of ethical
standing. If this was declined, I insisted I could not vote for the
amendment, for I would not pretend to offer bread and give a stone.
My proposition was not accepted, but the new rule was adopted with-
out my vote, and all i?i the name of the association.
" One other point deeply interested me, and determined my rejection
of office. It was well known that the rule, as adopted at Chicago,
which restricted the membership of the Congress upon ethical grounds,
had occasioned the resignation or withdrawal of many of the best and
strongest men in the profession, regardless of their views on the code
question. A conciliatory spirit on the part of the committee, as now
newly constituted, was of supreme importance, for we could ill afford
to do without so many of the good minds of the country. Under the
resolution of the association, the committee had power to fill all vacan-
Oct. 17, 1885.1
MISCELLANY.
447
cies occurring in its own body, and to appoint officers to the Congress.
This was regarded as implying the right to accept resignations from
positions which had been previously filled by the original Committee of
Eight, or by the present enlarged committee at its meeting in Chicago.
The work of filling vacancies was being pressed on, when the committee
had no knowledge of resig/iations except the mere verbal report of the
secretary. The idea seemed not to have occurred to any one that all
letters of resignation should be read before the committee, or that
courtesy and justice to the parties sending such letters demanded such
reading. It looked as if the officers of the committee, and not the com-
mittee itself, were, to use a trite expression, ' running the machine.' I
desired, naturally enough I thought, to know the reasons for the resig-
nations which had been sent in to the secretary, and therefore asked
for the reading of the letters. We were surprised to learn from the
secretary that the letters had been left in Philadelphia, and, besides,
that they were so numerous that there would scarcely be time for their
reading. I nevertheless urged that the telegraph should be used to
insure the letters' reaching us in due time. The secretary finally ar-
ranged to send a special messenger for the papers, and they arrived in
time for the second days' session. I now again called for the reading
of the letters. They were, under resolutions offered jn plea of press of
business, twice put upon the table to await convenience. But at last I
succeeded in having a few letters read. I heard enough to conclude
that if the obstructions to membership and to the honors of the Con-
gress were really removed, and a proper spirit of conciliation evidenced
by the committee, most useful merucould yet be saved to the Congress.
Meantime the work of filling the so-called vacancies in the most impor-
tant offices had continued without any questions as to the acceptance of
resignations. The spirit of vindictiveness (I regret to have to use the
term) under the presumed offense given by the parties who had pro-
posed to withdraw seemed to me to be irrepressible, so I could not
consent to occupy the position of vice-president in the Surgical Section
which had been assigned me, both by the original committee and the
present one. As an unavoidable engagement precluded my presence at
the meeting of the committee toward the close of the session, when the
list of vice-presidents of the sections was up for consideration, I left
with a member of the committee my written reasons for declining office.
These were read, but of course suppressed with other portions of the
minutes.
" In conclusion, let me state that I think it not unlikely that some
of my professional brethren will charge me with egotism, and condemn
the course I have pursued in thus publicly announcing personal griev-
ances. This I shall regret, but I apprehend there will be many who
will agree with me that personal grievances may be blended or iudis-
solubly connected with the interests of the whole profession. Had I
not regarded those which I have here recorded as of that category, I
should never have adverted to them.
" One word in relation to the gentlemen constituting the enlarged
committee. Many of them are my personal friends. I dispute not the
right of individual opinion. I claim no superiority over my brethren,
but my own convictions are strong and sincere. There are many of the
committee whom I know to be as conservative as I claim to be. I feel
grateful to some for the support I received while striving to modify the
determined policy of the majority. I intend no offense to the commit-
tee as a whole, unless it be an offense to offer the assurance that now
and ever I do not mean to allow my individuality to be destroyed.
" R. A. Kinloch,
"Member of Committee from South Carolina.
"Charleston, October 1, 1885."
The American Medical Association and the International Medical
Congress. — " The more one considers the question," says the " Medical
Times and Gazette," of London, " the more fatal do the objections ap-
pear to the principle of allowing a pre-existing medical association to
play the sole part in organizing an International Congress. No medical
organization whose aims are not purely and exclusively scientific can
ever be truly representative of medical science. The men who are the
real workers in the field of medical research, and who are therefore the
only proper representatives of the profession in a scientific meeting
like the International Congress, are hardly ever found playing a leading
part in associations of a medico-political natnre. Quite properly they
leave such functions to those of their brethren who have business pro-
clivities and time upon their hands. The latter class may be admirably
fitted for the work of conducting a large medical association, but they
are not qualified to greet on even terms the medical investigators of the
world, and we doubt even if they are competent to decide who are best
qualified to give that greeting. Thus there is always the risk, exempli-
fied in the United States just now, of their dragging the political and
ethical questions that are nearest to their hearts into competition with
purely scientific questions. The only safe way of organizing a success-
ful International Congress in any country is to leave it in the hands of
the leading scientific men, who are known and acceptable not only to
the hosts of the Congress, but also to its guests. We hope that on
some future occasion this principle, which has until now invariably
been acted upon, will be formally converted into a standing rule."
Decline the Invitation. — Under this caption the " Medical Record,"
of New York, says : " The month of grace allowed for the return of the
gentlemen who withdrew from the organization of the Ninth Interna-
tional Congress has passed. There are no signs yet of the hoped-for
return. The possibility, as suggested by us last week, of affecting in
some way the ruinous course of the present committee, is now destroyed
by the recent action of the Executive Committee, which has formally
assumed dictatorial powers. We think, therefore, that it would be bet-
ter, for the credit and harmony of the profession, that the acceptance
of the invitation to hold the Ninth International Medical Congress in
this country be withdrawn."
Excipients for Permanganate-of-Potassium Pills, — Mr. Edgar L.
Patch, of Boston ("Pharm. Record "), says that, when he first had occa-
sion to dispense permanganate-of-potassium pills, he chose that excipi-
ent nearest at hand which seemed to meet the requirements of making
a mass quite readily, and preserving the salt from rapid decomposition.
This was resin cerate, and, the permanganate being used in very fine
powder, the cerate met the first requirement so well that he persevered
in its use after Martindale had suggested the use of kaolin and paraffin,
and Proctor that of kaolin and water. He never kept the pills in stock,
and argued that their comparatively slow solubility was of advantage
in preventing the too powerful local action of the salt. Nevertheless,
some of his customers asked if the pills should " cause distress in the
stomach ? " He also recommended resin cerate to others who had stray
calls for the pills, and who found difficulty in obtaining kaolin. In-
quiry revealed the fact that at that time few wholesalers handled kao-
lin, and that some who sold " China clay " informed their customers
that they knew nothing of kaolin.
" Pure kaolin," he continues, " is a white clay, a hydrated silicate
of aluminium, having the formula H2Al2Si208 + HjO. Coming largely
from China, where it is found near the Kauling Mountains, it derives
its name Kaolin from the locality mentioned. It is also found in
France, Saxony, England, and various localities in America." Obtained
from three different localities, its composition varies somewhat, ferric
oxide, lime, magnesia, alkalies, and water being present in varying pro-
portions. Hence samples differ in plasticity when mixed with water,
and the many statements regarding its value as an exclpient may be
harmonized. After experimenting with the various excipients that
have been suggested, he recommends one of the following: 1. Resin
cerate, in proportion varied according to the size of the mass, from 15
to 20 per cent, of the finely powdered permanganate used. Five grains
will make a mass with 25 grains of the salt; 15 grains will make a
mass with 100 grains of salt. 2. One part of permanganate, l.J parts
of kaolin, and water, q. s." (Proctor.) The amount of water required
will vary from £ to f of a part. 3. Permanganate, 2 parts ; kaolin, 1
part; and petrolatum, q. s. The amount of petrolatum required de-
pends upon its consistence. He uses only i of a part; as, permanga-
nate, 24 grains; kaolin, 12 grains; petrolatum, 4 grains, makes a mass
somewhat more plastic than No. 1, and decidedly more so than No.
which has to be handled skillfully to get satisfactory results. Of the
three masses, No. 2, with kaolin and water, disintegrates rapidly in
contact with water ; No. 3 more slowly ; and No. 1 the slowest of all.
Of their permanence he is unable to speak from personal observation,
but it has been stated by Mr. George Smith (" Pharm. Journal," 1884)
MISCELLANY.
[N. Y. Mkd. Joor.
that masses made with kaolin and paraffin lose from 50 to 70 per cent,
by decomposition after six mouths' time. In view of this the pills
should be freshly made, and the pharmacist may work by any of the
three formulas suggested that best suits the case in hand.
Active Principles in Pharmacy.— Dr. R. G. Eccles, of Brooklyn,
contributes to the " Pharmaceutical Record " an important article on
" Infected Solutions," beginning with the following remarks :
" Aromatic w aters, dilute solutions of phosphoric, citric, tartaric,
oxalic, and other acids and their salts, as well as most alkaloidal solu-
tions, encourage the growth of a variety of aquatic crvptogamous
plants, whose polluting presence renders them unfit for use. They are
unwelcome visitors everywhere, but in the last-mentioned places they
are a great commercial misfortune, so that their suppression is a sub-
ject of growing interest. That it will continue so to grow is apparent
from the trend of medical science. Every advance made by therapeu-
tics discredits the use of tinctures, infusions, decoctions, extracts, etc.,
as at present indiscriminately prescribed.
" 1. Because all medication is found to be an injury to the svstem,
and on no account to be indulged in except to suppress a greater evil.
" 2. Because these preparations almost invariably contain some drug
not needed by the patient.
" 3. Because they often contain drugs positively contra-indicated by
the disease, combined with such as are pressingly necessary for the
same.
" 4. Because the strength of such preparations is never twice alike,
and it is merely an accidental guess when the proper dose is given.
" 5. Because the physiological effects of many drugs are found to
border upon the toxic. If too much is given the patient is injured; if
too little, he is insufficiently or not at all benefited.
" This is why the alkaloids of cinchona have, to so great an extent,
displaced the older forms of administration. This is why those of
belladonna, nux vomica, and opium are pressing forward in the same
direction. This is partially why cocaine has been found so useful at a
time when coca was about to be thrown aside as of little value. The
day of active principles in pharmacy is only beginning. Every year
must add to their popularity, and discredit to a great extent all that
now take their places. Definite solutions like Mageudie's will ere long
be in daily call, and these will represent all the virtues of the vegetable
world. There will then be no stimulating with alcohol when a depress-
ant is desirable, nor constipating with tannin when heart pressure only
is needed. Hypodermic medication points the way we are bound to
travel, and in this method of practice all the old drug preparations are
worse than useless. All the changes here foreshadowed will not come
in our day. Enough, however, will come to make the loss from infec-
tion become an item of financial importance. Cocaine at ten cents a
grain and eserine at twenty-five are worth saving. If we could calcu-
late the loss upon the former from this cause during the past year it
would no doubt amount to a snug sum."
The Health of Michigan.— Reports to the State Board of Health,
tabulated by the secretary, Dr. Henry B. Baker, show that during the
month of September diphtheria was noted at fifty-six places, scarlet
fever at forty-two, typhoid fever at forty-nine, and measles at five. As
compared with the averages for the corresponding month in the years
1879-1885, intermittent fever, remittent fever, dysentery, typho-mala-
rial fever, cholera infantum, cholera morbus, diarrhoea, pulmonary con-
sumption, and typhoid fever showed a diminished prevalence.
A New Journal of Therapeutics. — "Clinical Notes on the Local
Treatment of Disease ; a Record of Practical Therapeutics," is the title
of a new journal, edited and published by Dr. Charles L. Mitchell, of
Philadelphia. The first number, dated October, 1885, contains twenty
pages of reading matter, all on subjects of practical interest. Like Dr.
Squibb's " Ephemeris," " Clinical Notes " is designed for gratuitous cir-
culation, and the publisher does not bind himself to issue it at stated
periods, but only as material and circumstances may permit. From
Dr. Mitchell's well-known interest in therapeutical appliances, it is to
be expected that the journal will be one of value.
A Companion-Piece to " Per Orem."— The " Centralblatt fur Gynii-
kologie" heads one of its abstracts " Anteflexio uteri mit Stenosis ossis
interni," which can mean nothing else than anteflexion of the uterus
with stenosis of the internal bone !
THERAPEUTICAL NOTES.
Digitalis as a Cardiac Stimulant in Children. — At a recent meet-
ing of the New York Obstetrical Society a discussion took place on the
treatment of bronchitis in children. Speaking on the question of stimu-
lation, and limiting his remarks to cases of simple catarrhal bronchitis
in children between six months and a year old, Dr. A. Jacobi said that
in ordinary cases alcoholic stimulants were not necessary, but that he
never omitted the use of such cardiac roborants as digitalis. Like a
number of other drugs, digitalis, he said, was borne by children in
relatively large doses, and he had found it act better as a cardiac stimu-
lant if given in two or three large doses each day than if given in small
doses frequently repeated. For children of the age mentioned he would
gave a grain twice a day.
Cocaine in the Treatment of Whooping-Cough. — Dr. Moncorvo, of
Rio de Janeiro (" Uniao Med."), who has written forcibly in commenda-
tion of the use of resorcin in the treatment of whooping-cough, now
recommends hydrochlorate of cocaine as an adjuvant. The throat is
to be swabbed with a ten-per-cent. solution of cocaine. In a few
minutes the parasiticidal solution of resorcin may be applied to the
same parts without provoking either pain, vomiting, or a paroxysm of
coughing.
Styptics and Depressants in the Treatment of Haemoptysis. —
Apropos of a recent article on the treatment of haemoptysis, by Mr. W.
H. Kesteven, Dr. Godwin Timms, senior physician to the North London
Consumption Hospital, writes to the " Lancet " that, for the last twenty-
five years, he has treated haemoptysis with tartarized antimony, one
sixteenth of a grain, in a saline draught, every hour or two. Where
the profuseness of the haemorrhage or the patient's anxiety makes it
advisable to produce an immediate effect, forty minims of oil of turpen-
tine are given every two hours, in a wineglassful of water. He adds that
this treatment is most successful, except in the rapidly fatal cases in
which the hcemorrhage comes from the bursting of a small aneurysm.
On the other hand, Mr. F. W. Allwright, of Beaconsfield, writes to the
same journal in recommendation of astringents. He can not imagine
how depressants can stop bleeding, and says that he would never again
try ipecacuanha.
Beef Powder in the Treatment of Simple Ulcer of the Stomach. —
Under the inspiration of M. Debove, M. A. L. Pradet has written a
work on the treatment of simple ulcer of the stomach, in which, as we
learn from a review in the " Union medicale," he recommends the use
of a mixture of beef-powder and bicarbonate of sodium. Small doses,
he says, should be used for the first two days, but afterward 1,500
grains of beef powder {jpoudre de viande) and 450 grains of bicarbonate
of sodium may be given daily to a man, and 1,125 grains of beef pow-
der and 360 grains of the sodium salt to a woman. The treatment
should be pursued until complete recovery has taken place, and it is
only with extreme carefulness that the patient should be allowed to re-
sume the use of ordinary food.
A Palliative of the Pains of Dyspepsia. — The same journal attrib-
utes the following prescription to M. G. See :
Tincture of hvoscvamus ) , , -~ .
J - y each 150 grains;
Tincture of conium )
Tincture of gentian 75 "
Essence of anise 10 drops.
From ten to thirty drops are to be taken with each meal, as a reme-
dy for the pains of dyspepsia and cancer of the stomach.
Oxygen in the Treatment of Leuchaemia and Pseudo-leuchaemia.
— Kirnberger (" Dtsch. med. Wchnschr."; "Union med.") reports a
case in which, after the failure of arsenical treatment, inhalations of
oxygen produced a rapid increase of strength, with diminution of the
swelling of the spleen, the white globules becoming less numerous, and
the red globules regaining their normal proportion. After a few months
a relapse took place, but, although the red corpuscles were diminished
in number, the white ones were not increased — a condition termed
pseudo-leuchamiia. Finally, arsenic having again failed, the inhalations
led to a definitive cure.
THE JSTEW YORK MEDICAL JOURNAL, October 24, 1885
#rigmal Communications.
CONTAGIOUS CONJUNCTIVITIS ;
ITS CAUSES, PREVENTION, -AND TREATMENT.*
By JOSEPH A. ANDREWS, M. D.,
MEMBER OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY J OPHTHALMIC SUR-
GEON TO CHARITY HOSPITAL, NEW YORK, ETC.
The literature of bacteriology fairly bubbles over with
ingenious hypotheses ; and yet the germ theory of disease
is justly one of the chief principles of modern science, and
substantial facts are steadily being brought forward to
prove the influence of bacteria as morbific agents. It cer-
tainly is true that reports have reached us which would
seem to negative the deductions from some of the experi-
ments of prominent workers in this field of investigation ;
but there has been a great deal of hasty and groundless op-
position to these researches. However, the inquiry into this
matter is being vigorously pushed by skillful workers in the
laboratories of Germany and France, and research of such
vast importance to the whole human race deserves the
greatest possible encouragement, and should not be re-
garded alone with the intellectual interest which theoretical
inquiry excites.
The views which I shall have the privilege to lay before
you this evening are the outcome of a practical inquiry
into the cause and prevention of contagious conjunctivitis.
I can only regret that the case of successful inoculation of
a pure culture of the gonococcus which I made a short time
since did not have for its field of operation a healthy human
tissue ; however, it is for others to decide whether the re-
sult obtained be of value or not.
In May, 1882,f Neisser declared that the gonococcus
originally described by him in 1879 was the pathological
principle of gonorrhoea; that it wras the actual contagium of
the gonorrhoeal affection. That the presence of a micrococ-
cus form is constant in the secretion of gonorrhoea has been
confirmed by Bokai, Weiss, Aufrecht, Ehrlich, Brieger,
Gaffky, Sattler, Leber, Haab, Hirschberg, Sternberg, and
others ; but all writers are not agreed that the micrococci
they have seen in gonorrhoeal pus were those occurring only
in gonorrhoea, or the same which are found in all pus which
has been exposed to the air, or that they differ in form and
size or in other characteristics from the micrococci of
other blennorrhoeas. Neisser maintains that the " gonococ-
cus" is a specific kind of coccus, which is not alone func-
tionally but morphologically characteristic.
According to its discoverer (Neisser), the gonococcus is
comparatively large, flattened on the side which is turned
toward its neighbor, somewhat oval, seldom single, almost
throughout double. It lies close to its neighbor with only
a fine fissure between the two; in shape it is " semmel-
fdrmiff." It multiplies by division transversely, forming a
bair, these dividing at right angles to the first line of divi-
sion, thus forming a group of four ; they never occur in the
* Read before the New York Academy of Medicine, June 18, 1885.
f " Deutsche med. Wochenschrift," No. 20, 1882, p. 279.
chain-form ; they are found free in the fluid, or more fre-
quently adherent to the pus-corpuscle and epithelium. The
arrangement in groups of two and four is constant in gonor-
rhoeal pus, and, although this grouping is sometimes seen in
specimens of pus from other sources, the chain-form is the
more common in them. Bockhart found the gonococcus
group mostly on the pus-cells or their nuclei, never in their
interior; Haab, on the contrary, found them within the
nuclei.
Eklund * denies that the gonococcus is alone specific for
gonorrhoea, because he professes to have found similar or-
ganisms in acute and chronic purulent processes in the lungs
and intestines, in ulcerative stomatitis, etc. But the bac-
terium of gonorrhoea seems to possess an ability which all
forms which resemble it do not — viz., that of penetrating
into the living cell protoplasm and of multiplying in it ; but
this power is soon exhausted.
In the normal human saliva there are micrococci which
resemble those of gonorrhoeal pus ; but, if there is a mor-
phological resemblance, their functional characteristics are,
at least, not the same as those of the gonococci. There is
a short, thick bacterium in the vaginal secretion, swelled by
coloring agents and looking like a diplococcus. Bumm and
Bockhart profess to have found the " semmelformig " diplo-
coccus in the secretion of the female genitals, in diphtheritic
sores, in ulcerative process in the mouth, and in a prep-
aration of the sputum of a patient with whooping-cough.
Welander f found Neisser's gonococcus in all cases in which
he looked for it — among 129 cases of acute and 15 cases of
chronic urethral blennorrhoea ; even cases of eight to six-
teen months' duration were not excepted.
Neisser twice saw profuse purulent discharge from the
urethra of a man which occurred after very frequent cathe-
terization preparatory to lithotrity. The secretion contained
abundant evidence of the presence of bacteria, but no gono-
cocci were found.
In my case of successful inoculation of a pure cultivation
of gonococcus I proceeded in the following manner: The cul-
tivation medium was serum of the blood of the ox, prepared
according to Koch's directions, being heated daily one hour,
for six successive days, to 58° C, and thus sterilized and ge-
latinized by subjecting the serum to a temperature of 65° C.
A small quantity of fresh pus from a case of acute urethral
gonorrhoea was allowed to drop from the urethra on to the
sterilized platinum-wire, and then to drop off the latter, leav-
ing only a thin layer of pus on the wire ; the wire, thus
charged, was thrust into the firm blood-serum in three or
four different places, and the test-tube closed with sterilized
cotton-wool; a number of test-tubes were thus planted and
placed at once in the incubator, the temperature of which
was maintained in different cultivations at 32°-36° C. After
about twenty-four hours, further inoculations were made
from the first tubes. With the seventh generation I inocu-
lated a human conjunctiva. The case was one of granular
* F. Eklund, " Note sur les microbes de la blennorrhagie," cited in
Schmidt's " Jahrbucher," Bd. exevii, 1883, p. 139.
f Reviewed in " Vierteljahresschrift f. Dermatologie u. Syphilis,"
1884, p. 178.
450
ANDREWS: CONTAGIOUS CONJUNCTIVITIS.
[N. Y. Med. Jook.,
conjunctivitis in stadio cicatricio and with dense pannus, but
nvithout purulent secretion or any discoverable cocci in the
conjunctival secretion. The choice of treatment lay between
the use of jequirity and inoculation with gonorrhoeal pus.
Nothing was concealed from the patient, and he sanctioned
the inoculation with full knowledge of what the consequences
might be. I had unsuccessfully inoculated so many differ-
ent animals with cultures of the gonococcus that I hailed
with extreme delight this opportunity to make the trial in
the case of a human being. Three weeks previous to this
operation I had inoculated the same eye with a pure cultiva-
tion of the coccus taken from my own saliva, the result hav-
ing been negative. I prepared the conjunctiva for the re-
ception of the pure cultivation of the gonococcus by washing
the conjunctival surface for several days with pure water.
I then conveyed the cultivation to the conjunctival sac and
bound up the eye with a roller bandage and absorbent
cotton-wool, due attention having been given to the con-
dition of these things. The result was a perfect picture of
gonorrhoeal conjunctivitis with abundant evidences of the
presence of the gonococcus.
Bockhart * obtained a successful inoculation, from a
pure cultivation (gelatin) of the fourth generation of the
gonococcus, on the sound human urethral mucous membrane.
The subject of the experiment was a forty-six-year-old para-
lytic whose death was expected daily. On the sixth day
a typical gonorrhoea was formed, which increased in sever-
ity up to the twelfth day, when the patient died. The
characteristic gonococci were found in the secretion.
Sternberg's criticism on this case is, that the fourth suc-
cessive cultivation is not sufficient to insure the exclusion of
the original material — "a hypothetical non-living virus" —
" when the cultivation is conducted upon a solid substratum."
Sternberg did not succeed in producing urethral gonor-
rhoea in himself and two others with a pure culture of the
gonococcus.
Loeffler and Leistikow f had negative results after inocu-
lation of apes, dogs, and rabbits with a pure growth of the
gonococcus.
Krause J cultivated the cocci from ophthalmia neonati
on blood-serum, and with the pure cultivation inoculated the
cornea, conjunctival sac, and urethra of full-grown rabbits,
and adopted the same procedure in the case of young cats,
pigeons, and mice ; but these experiments, as well as subcu-
taneous inoculation of rabbits and mice, were without re-
sult. Krause then inoculated the conjunctival sac of new-
born rabbits (six to ten days old) with the same cultiva-
tions (from ophthalmia neonati), and produced a purulent
conjunctivitis, which was present twenty-four hours after
the transfer, and in the course of the following days
became more intense. Three of the rabbits died, on the
fifth and seventh days after the inoculation, from other
causes ; one animal lived for some time ; in this one, on the
tenth day there had developed a very profuse purulent
* " Beitrag zur Aetiologie und Pathologie des Harntrippers : " " Vier-
teljahresschrift f. Dermatologie u. Syphilis," 1883, Heft i, p. 8.
f " Verhandlungen der Gesellsehaft der Charite-Acrzte zu Berlin,"
Sitzung vom 16 Februar, 1882.
\ " Centralblatt f. prakt. Augenheilk.," May, 1882, p. 137.
discharge from the conjunctiva; the pus had the ordi-
nary cheesy character of rabbit's pus, and contained, in
addition to bacterial contaminations, numerous cocci which
were somewhat smaller than those of Neisser. On the fol-
lowing day there was an abscess of the cornea, which per-
forated the latter. Krause does not assert that this result
should be accepted as conclusive. He maintains that in
this case Neisser's gonococcus was the active agent in the
infection.
The successful inoculation of the urethras of three medi-
cal students with gonococci cultivated by Bokai can not be
accepted as conclusive, because of the manner in which the
cultivation was conducted.
It appears that animals are not susceptible to the poison
of gonorrhoeal pus, neither the cocci nor the pus itself
being capable of reproducing the disease in them.
What interests us most is whether the gonococcus is the
cause of gonorrhoea in the human subject; and when the
objection, that the essential agent in the infection is a solu-
ble unorganized substance contained in the pus used for
inoculation of the cultivation medium, has been removed by
isolation of the coccus, and the disease is induced with it
alone, then we have very strong facts to argue from.
Etiology of Ophthalmia Neonati. — According to
von Graefe, all inflammations of the conjunctiva are con-
tagious through the secretion which they furnish — conta-
gious in the sense that this secretion must be conveyed to
the conjunctival sac of a healthy eye. The more intense
the swelling and discharge from the original diseased mu-
cous membrane, and the more acute the inflammation of
the latter at the time of the conveyance, the more active
will be the poison. The hypothesis of contagion through
the air was admitted by von Graefe, and is still held by
some excellent observers ; but infection through this source,
I feel sure, is quite rare, and, when there seems to be no
other source than the atmosphere to fall back upon in a
given case of contagious eye-disease, we should still refer
to the atmosphere as a probable source of infection with
misgivings.
The chief cause of ophthalmia neonati is infection de-
rived from the genitals of the mother, either at the time of
birth of the child or a short time afterward, the poison in
the latter instance being transferred to the child — healthy
at birth— through the medium of the bath-water, but much
more probably through sponges, towels, etc.
Crede maintains that a pure catarrhal secretion of the
genitals does not produce blennorrhoea, but Haussmann*
says that the vaginal secretion may be infectious. Zweifel f
inoculated normal lochial secretion upon the conjunctiva of
the new-born in six cases without producing blennorrhoea
even once. .1 inoculated normal lochial secretion upon the
conjunctiva of the new-born in three instances, the result
being negative. In spite of these facts, it has been main-
tained that the normal lochia does give rise to conjunctival
blennorrhoea. But there is no positive proof that this is
anything more than a mere assertion.
* " Archiv f. Gyniikologie," 1881, Bd. xxi, p. 523.
f "Archiv f. Gyniikol.," Bd. xxii, p. 329 ; see, also, his recent com-
munication on these cases, same Archives, Bd. xxiii, p. 325.
Oct. 24, 1885.J
ANDREWS: CONTAGIOUS CONJUNCTIVITIS.
451
We know .that gonorrhoeal pus, placed' in a healthy
human conjunctival sac, gives rise to the same disease with
the precision of a physical experiment ; therefore the view
that normal lochial secretion produces conjunctival blen-
norrhcea in one person and not in another seems, according
to this reasoning, to be untenable.
I believe that the infection occurs some time after the
birth of the child much more frequently than is generally
supposed, the original source of the infection being the
same as in the first instance ; and from this original cause
many other eyes may be infected by direct conveyance of
the poison to them by the mother or nurse. I could cite
many instances in my own experience to support this state-
ment. The cases of purulent conjunctivitis which occurred
in my service at the Nursery and Child's Hospital (Country
Branch) in 1879 originated in this way.
At the Foundling Hospital in St. Petersburg during six
years 2,918 cases of ophthalmia neonatorum were observed,
and simultaneously 345 wet-nurses of the children were at-
tacked with the same disease. *
Theremin f has recorded a table from the same institu-
tion embracing six subsequent years, according to which
476 cases of " blepharo-blennorrhoea " occurred, and the
relative frequency of the disease at and after birth is indi-
cated as follows : On the first to the fourth day, fifty-seven
cases ; from the fourth to the eighth day, one hundred and
thirty -four cases; from the eighth to the fourteenth day,
ninety-four cases ; later, one hundred and ninety-one cases.
Olshausen thinks that when the disease occurs after the
fourth day the child was infected after birth. Although
ophthalmia is infrequent among the better class of patients,
it is quite common among the ignorant poor, and the homes
of such people are constantly menaced by the danger of a
child at the breast, already a victim of the disease in ques-
tion, infecting the whole family. Haussmann thinks that
the purulent secretion from a sore nipple may become a
source of infection.
The question has been freely discussed as to whether
Neisser's gonococcus is the special bacterium of this dis-
ease. Whoever may be interested in reading over the con-
tradictory views on this subject will find an abundance of
material in Haussmann's work, " Die Bindehautaffection der
Neugeborenen," Stuttgart, 1882. Leopold and Wessel %
tell us that, of eighteen mothers whose children were not
placed under prophylactic treatment, gonococci were found
only in the case of one mother, and, on the third day after
the birth of her child, the latter presented the familiar ap-
pearances of conjunctival blennorrhoea. No gonococci could
be found among the remaining seventeen women, and their
children remained free from any inflammation of the eyes.
Their article contains many instructive details which it would
be quite impracticable to incorporate in the present paper,
which has already assumed proportions much greater than
I had originally prescribed for it.
* Froebelius, " Medicinische Zeitimg Russlands," 1885, Bd. xii, No.
33, p. 257 ; cited by Haussmann.
f " St. Petersburger med. Zeitsehrift," Bd. v, p. 97 ; cited by Hauss-
mann.
% " Archiv f. Gynakol.," 1884, Bd. xxiv, p. 93.
Haussmann * cites the statistics of Cederskjbld, of Stock-
holm, according to whom the eyes of the children of moth-
ers with blennorrhoea were diseased in 14"6 per cent., and
of the children of mothers free from blennorrhoea only
5-52 per cent, were affected. But the 5"52 per cent., were
they not infected by the others ?
Granular Conjunctivitis. — At the Ophthalmic Con-
gress in Heidelberg, in 1881, Prof. Sattler announced that
he had succeeded in finding in the conjunctiva of granular
conjunctivitis micrococci which resembled those of Neisser,
and that with a pure cultivation of those cocci he had repro-
duced the disease in question in a man. Leber confirms
Sattler's statement as to the finding of cocci in the tissue
of granular conjunctivitis. About thirty years ago Arlt f
taught that there was an intimate relationship between
granular conjunctivitis and struma, also tuberculosis. This
view has been pretty generally abandoned by ophthalmolo-
gists of the present time, and Sattler's discovery might dis-
pose us still further to differ with Arlt, but it is very proba-
ble that Sattler is in error in this matter. 1 have searched
in vain for any micrococcus form in the tissue of granular
conjunctivitis. In a paper published last year J I gave the
details of the manner in which I had proceeded in inves-
tigating this question. I had examined 1,500 sections taken
from 37 cases of trachoma without being able to find any
cocci in them. I have since carefully examined five cases
of this disease, with the same end in view, but, although I
have applied the proper staining agents and the other indis-
pensable aids in such examinations — i. e., Abbe's condenser
and the homogeneous immersion of Zeiss — I have never suc-
ceeded in finding any cocci in these tissues, except in cases
of trachoma accompanied by an active catarrhal process. But
cocci are found in the secretion of granular conjunctivitis, and
the disease is unquestionably contagious, and the secretion is
the carrier of this contagion ; but there is this peculiarity
about the disease, that it requires that certain constitu-
tional conditions shall obtain in order that the disease may
be reproduced in another to whose eye the secretion has
been transferred. It is a clinical fact that struma and
trachoma generally go hand in hand, and overcrowding,
filth, and poor food are the essential factors in the produc-
tion of this terrible disease.
Diphtheritic Conjunctivitis. — Fortunately for us, diph-
theritic conjunctivitis is a rare disease in this country. Its
mode of origin and course harmonize thoroughly with the
doctrine of its dependence upon pathogenic micro-organ-
isms. Its contagiousness is undisputed, and the germ the-
ory affords the best explanation of its phenomena ; and yet,
in spite of many elaborate researches, the precise nature of
the diphtheritic virus is still a matter of doubt. The ma-
jority of those who have studied the question from the
pathological and experimental side declare in favor of a
specific micrococcus which is found imbedded not only in
the membranous deposit, but also in the lymphatic spaces,
beneath the mucous membrane, in the blood, and in the in-
* " Die Bindehautaffection der Neugeborenen," Stuttgart, 1882,
p. 22.
f "Die Krankheiten des Auges," Prag, 1858, i, pp. 130, 131.
X "Archives of Medicine," vol. xi, June, 1884, p. 221.
452
CCRRIER: 0 ONORRH CEA IN THE FEMALE.
ternal organs — Oertel, Eberth, and Klebs. Loeffler * details
an extensive experimental inquiry upon diphtheria in ani-
mals and man. He confirms the fact that micrococci pre-
vail in diphtheritic membrane mingled with other forms of
bacterial life, which find a suitable nidus in the necrosed
and decomposing tissue ; but he lays special stress, from
tbe serological point of view, upon the presence of a ba-
cillus first made known by Klebs. This organism invari-
ably occurs in association with the micrococci, but pre-
sents, far more than these do, the attributes of a specific
virus.
The micro-organism which Emmerich f alleges to be
distinctive occurs in the diphtheritic lesions both of the
pigeon and of man, is neither a coccus nor a bacillus, but a
short, thick bacterium, which, in gelatin cultivations, forms
a pellucid, grayish color, assuming a whitish appearance as it
develops, and not liquefying the gelatin. It grows luxu-
riantly on the potato, forming on it a thick yellowish-
white layer, but in blood-serum the bacterium does not
grow well. In form, size, and mode of growth the diph-
therial bacterium of man is identical with that of the
pigeon. Inoculations were successfully made with this or-
ganism. But very great difference of opinion prevails
among bacteriologists themselves as to the morphology of
the diphtherial fungus. Emmerich thinks diphtheria is
essentially a house-disease, prevailing in those seasons in
which dwellings are most likely to be overcrowded.
(To be concluded.)
GONORRHOEA IN THE FEMALE.
By ANDREW F. CURRIER, M. D.,
NEW YORK.
( Concluded from page 426.)
II. — Certain forms of this disease are much better
known and much more readily recognized than others^
With many physicians gonorrhoea in the female is synony-
mous with elytritis, and it will be readily conceded that
this is by far the most common form, though not always
the one which is most susceptible of successful treatment.
I may here repeat the statement which I made in my first
paper, that the loose tissue in the posterior vaginal fornix
is very commonly a source of trouble when all other por-
tions of the mucous membrane have been cured. This area
can only be exposed by the use of Sims's speculum, or some
similar instrument, with a good light either direct or re-
flected. The mucous membrane of the cervical canal may
be involved as a primary or a secondary condition, and its
rich glandular structure furnishes abundant opportunity for
the accumulation of infectious material, to be propagated
thence beyond the os internum. In many cases, however,
it is limited by the os internum, and is wholly or in part
eradicated by the use of suitable means. Less frequently
the urethra and bladder are affected, this being especially
true of the bladder. The anatomical relations of the mea-
* Friederieh Loeffler, " Mittheilungen aus dem kaiserlichen Gesund.
heitsarote," Bd. ii, 1884, p. 421.
f Rt Emmerich, " Deut. med. Wocbensehrift," 1884, No. 38, p. 614.
tus and urethra explain the infrequency of the disease, as a
primary condition, in these parts in women. The dis-
charges of the urethra in such cases abound with gonococci,
and Welander, Belleli, and others have made observations
upon this subject, Belleli having obtained specimens from a
large number of prostitutes at the bureau de visite in Alex-
andria, Egypt (see " Unione med. egiziana," Nov. 1, 1884).
An extension from the bladder to the ureters and kidnevs
is a possibility, and has been referred to by Sanger, but he
mentions no cases which he has seen or heard of. The
condition must be one of great rarity. The vulvar glands
with their ducts and circum-glandular tissue, the rectum, and
the skin around the external genitals, may all, or any of
them, be the seat of the phenomena of this disease ; like-
wise the mucous membrane of the body of the uterus and.
of the Fallopian tubes. That an extension of the process,
by way of the Fallopian tubes, to the ovaries, the parame-
trium, and the general peritonaeum may occur, and cause
fatal peritonitis, is not only a possibility, but a fact which
has been observed from a period at least as remote as 1846,
when Mercier published the results of his investigations in
the dead-house ("Gaz. des hop.," 1846, p. 432). In fact,
Sanger states (loc. cit.) that this disease is the cause of a
larger percentage of grave chronic abdominal diseases than
puerperal fever or syphilis. The weighty evidence of Law-
son Tait as to its gravity is also given as a result of his
extensive experience (see " N. Y. Med. Jour.," 1884, p
421). Thus the profession is approaching the views that
Noeggerath enunciated in 1872, which, as he prophesied,
have borne fruit with the years.
A form of the disease which, until recently, was over-
looked, is that which involves the peri-urethral or pre-
urethral glands, and upon which papers have been written
by Martineau (" Bull, et mem. de la soc. de therap.," Paris,
1884, 2 s., xiv, 81), by his pupil Guedeney (Inaug. Thesis,
" Contrib. a l'etude de la blennorrhagie chez la femine,"
Paris, 1883), by A. Guerin, under the name of .external
blennorrhagie urethritis, by Hamonic ("Ann. de dermat. et
de syphil," August 25, 1883), and by Skene in the course
of a lecture upon " Vaginitis and Vulvitis " (" Med. News,"
Philadelphia, 1884, xliv, p. 29). The glands or follicles,
which are most often the seat of this trouble, were de-
scribed in 1864 by A. Guerin, and correspond to the ancient
descriptions of a body which is supposed to be the analogue
of the prostate. They surround, or partly surround, the
urethra near the meatus, sometimes being joined in the
median line, at others being separated by a bridge of tissue.
Their ducts pass upward within the vestibule and open on
either side of, and just under, the clitoris. The inflamma-
tion which affects them may be aCute, or it may be exceed-
ingly chronic, persisting long after all apparent symptoms
have disappeared. Martineau says (loc. cit.) he has repeat-
edly found gonococci in the discharges which he has ob-
tained from these chronic cases. If, therefore, infectious
power resides in the gonococcus, we can readily see how a
woman who thinks herself cured may be suffering from
latent gonorrhoea, and prove unintentionally and unknow-
ingly a source of infection. This also explains the state-
ment of Ricord, that a woman may communicate gonorrhoea
:Oct. 24, 1885.J
CURRIER: QONORRHCEA IN THE FEMALE.
453
when she does not possess it herself, which was doubtless as
much of an enigma to him as his statement was illogical and
absurd. Allusion has already been made to a variety of
this disease to which I wish to call especial attention, be-
cause it is one of the gravest varieties, and has received
considerable attention within the past year or two, notably
at the hands of Lavvson Tait. It is that variety which
affects the Fallopian tubes. The pathology of these organs
,has been sufficiently investigated to inform us that, in addi-
tion to simple catarrh, hydrosalpinx, and hematosalpinx^
there are other more serious conditions which, according to
Sanger (loc. cit.), are usually of an infectious nature, and
•are either tubercular, syphilitic, actinomycotic, or gonor-
rhoeal in character. Of these the gonorrhoea] form is the
most frequent. It is usually met with as pyosalpinx, but
the latter is not necessarily of gonorrhceal origin. The
diagnosis rests upon the discovery of gonococci. If these
are found in the discharges from the genital passages, and
tubal disease is evident, removal of these organs will proba-
bly reveal the organisms in the secretions which they con-
tain, or in the mucous membrane itself. The diagnosis of
tubal disease by palpation is, however, a matter of extreme
difficulty, in which very few men have ever attained expert-
ness. Even Lawson Tait says he is mistaken once in every
five cases (" N. Y. Med. Jour.," 1884, p. 421). In the light
of such testimony too much caution can not be observed in
pronouncing opinions respecting such conditions. Autop-
sies upon the bodies of prostitutes have frequently revealed
an inflamed, dilated, and dislocated condition of the tubes,
which is at least suggestive of gonorrhceal disease, an opin-
ion which is shared by Sanger and Tait. Finally, Sanger
has described a form of this disease which he calls puerpero-
gonorrhoeal salpingitis, which may be excited in a recently
delivered woman by a latent or acute gonorrhoea of her
husband. Such a distinction seems quite superfluous, as it
does not appear that the phenomena differ from those
which are manifested in other women. The influence
which gonorrhoea exerts upon fecundity was elaborately
expressed by Noeggerath in the paper to which allusion
has been so frequently made. In a great many cases ste-
rility is unquestionably the result. In prostitutes especially
it is fair to presume that the infrequent pregnancies are in-
fluenced by this cause. Should gonorrhoea supervene after
pregnancy has been established, I have never seen that it
exerted an influence upon the mother severe enough to pro-
duce a miscarriage, nor upon the foetus any that was analo-
gous to that of syphilis. In cases of congenital ophthalmia
neonatorum the theory has been advanced that the gono-
cocci traversed the foetal envelopes and the amniotic fluid
and penetrated the foetal conjunctiva. But why such a
process of selection should be followed, the eyes being
chosen instead of the urethra, or some other opening which
is lined with mucous membrane, does not appear. It is
also probable that the eyelids are always closed in utero,
though this might not prove an efficient barrier to the pene-
tration of the microbes.
III. — In discussing the question of treatment, attention
must be given to the value of a wise and judicious prophy-
laxis. Especially should prostitutes — that large class of
individuals which society tolerates at such an enormous cost
to itself in every way — receive attention of this character.
Leaving the moral aspect of the question out of considera-
tion for the present, although this ought to be sufficient to
arouse the sympathy of any one who has the welfare of
his fellow-beings at heart, it is perfectly clear that any class
of individuals which distributes infectious disease in the
community should be under police regulations. It matters
not what the disease is, so long as it is a source of danger
to the community. The reply to this may be that there is
a distinction between infectious diseases which one avoids
and those which one dares or defies, of which small-pox will
serve as the type of one and gonorrhoea of the other. My
rejoinder is that the community — the Government, State and
municipal — either tolerates prostitution by taking no steps
to suppress it, or it licenses it; and therefore it ought to
protect the citizen from the infectious diseases which it en-
tails. I confess that I have no elaborate scheme to offer
for the accomplishment of this great end, but the remedy
lies in the direction of a properly systematized medical
police, with suitable hospitals or stations properly equipped ;
and this will come when public opinion is aroused to the
necessities of the situation through the enlightened instruc-
tion of the medical profession.
Injections of sublimate, carbolic acid, iodized alcohol,
dilute nitric acid, nitrate of silver, and other germicides
have been recommended as prophylactic means, both for
prostitutes and those who consort with them ; but any one
who has had experience with these classes will readily real-
ize that this plan simply places dangerous remedies in the
hands of individuals who are usually either reckless or ig-
norant in their use of them. Another important point in
connection with the subject of prophylaxis has reference to
the consummation of marriage on the part of women who
are suffering, or have suffered, from gonorrhoea, and such
women are by no means confined to the class of prostitutes,
as any physician of experience is able to testify. Any one
who has seen the mischief which is wrought in families by
the discovery of such a condition will surely make the
requirements not less stringent before giving his profes-
sional consent to marriage than if the gonorrhoea had been
in the male instead of the female. As long as gonococci
can be found in the discharges, that consent should be un-
hesitatingly withheld. The pathogenic nature of the micro-
coccus being admitted, the treatment will naturally be di-
rected chiefly at its vitality. Whatever theory be adopted
as to the nature of the disease, those agents must be used
which will stop the offensive discharges, relieve congestion,
and produce a healthy tone of the affected tissues with
their vessels and nerves. Oppenheimer has made a large
series of experiments bearing upon this subject, which are
both interesting and important (loc. cit.). He first tried to
cultivate gonococci by using fresh gonorrhceal pus from a
patient in the acute stage of the disease who had not yet
been treated. The pus was mixed with one part urine gela-
tin, two parts water, and three per cent, of meat-peptone.
This experiment was unsuccessful, but was followed by one
which was successful, in which sterilized blood-serum was
used as the cultivation-fluid. The microbes were developed
454
CURRIER: QONORRHCEA IN THE FEMALE.
[N. Y. Med. Jock.,
upon pieces of thread which were laid in the serum.* No
effect was produced upon their vitality hy solutions of sub-
nitrate of bismuth, acetate of lead, or alum. Slight effect
was produced by strong solutions of sulphate of copper,
zinc, or iron, and chloride of zinc. Development was ar-
rested by a two-per-cent. solution of nitrate of silver.f
Of the mercurials, a solution of 1 to 15,000 of the ni-
trate or sulphate retarded development, 1 to 10,000 de-
stroyed vitality ; 1 to 40,000 of sublimate retarded devel-
opment, 1 to 20,000 destroyed vitality. Solutions of mer-
curial salts in glycerin were equally effective with watery
solutions. Chlorate of potassium or of sodium in solu-
tion was ineffective, the former being used to the limit of
saturation. Permanganate of potassium was destructive in
l-to-25 solutions; in l-to-50 solutions it retarded develop-
ment ; it was entirely inert in the weak solutions which
have been recommended by Zeissl. Moderately strong solu-
tions of bromine, chlorine, and iodine destroyed the mi-
crobes, while methylic and ethylic alcohol, sulphuric ether,
glycerin, and chloroform were effective only when used un-
diluted. Tannin and resorcin were inert. Five-per-cent. solu-
tions of carbolic acid destroyed life in ten minutes ; one-per-
cent, solutions only retarded development. Watery solutions
of thymol and salicylic acid of sufficient strength to excite
inflammation in normal tissues did not kill the organisms,
while alcoholic solutions of the same strength were efficient.
This is the more remarkable since alcohol alone was not de-
structive. Fifty-percent, solutions of creasote were rapidly
fatal. Turpentine was quite effective ; balsam of copaiba
and cubeb extract were harmless. It was thought possible
that the well-known efficiency of cubebs and copaiba in the
practical treatment of gonorrhoea might be due to chemical
changes which the drugs underwent in the system. This
matter was tested by using specimens of urine drawn from
the bladder of a pregnant woman through a heated metallic
catheter. The urine was normal in character and had no
influence upon gonococci. Two doses of copaiba balsam
were then given to the patient, of fifteen grains each, and with
an interval of three hours between them. The urine was
then drawn with the precautions mentioned, and was found
to contain conversion products (Umsetzungsproducte) of
the balsam. Threads upon which cocci had been developed
were immersed in this, and allowed to remain eighteen
hours. At the end of that time they were transferred to a
cultivation-fluid, but no development occurred. The same
result followed experiments with cubebs. The supposition is
therefore warrantable that these substances undergo chemi-
cal change, and, after elimination by the kidneys, perform
their work upon the cocci in the genital tract. Oppenheim-
er's conclusion is that only sublimate, creasote, and nitrate
of silver are of any practical use for the destruction of
gonococci, and he is entitled to a respectful hearing, for no
* The vitality of the microbes was seen in the fact that they sur-
vived the drying of the cultivation-fluid, and this fact may be of impor-
tance in explaining some obscure cases of infection in which all neces-
sary precautions are supposed to have been taken.
f This is the solution which was recommended by Crede a few years
ago as a prophylactic against ophthalmia neonatorum, and has come
into very general use for this purpose.
one, apparently, has investigated this subject more exhaust-
ively or patiently. There is a factor, however, which is
not embraced in any investigation of this character — name-
ly, that of idiosyncrasy or personal peculiarity, and the
mysterious changes which occur within the tissues and cavi-
ties of the body can not be exactly reproduced outside the
body, because the conditions can never be exactly the same.
It is, therefore, clinical rather than purely experimental re-
sults by which we must finally be guided. To illustrate,
Oppenheimer found solutions of chlorate of potassium inert
in their effect upon gonococci, but a gentleman of extensive
experience assured me that they were quite efficient, with
him, in subduing all the phenomena of gonorrhoea. Oppen-
heimer found resorcin inert, but Martineau (Joe. cit.) ob-
tained good results from its use. Rebatel recommends a
weak injection (vaginal) of salicylic and citric acids, or of a
decoction of lemon, for their efficiency in the gonorrhoea of
females, which would, doubtless, have little effect upon Op-
penheimer's cultivated gonococci. On the other hand, I
have found, in a large number of cases, that the sublimate
treatment (that is, by local applications) was quite unsatis-
factory, and this experience is similar to that of Kroner,
Schatz, and von Tischendorf. Oppenheimer places it at the
head of the list of gonococcicides. Von Tischendorf's best
results were with irrigations of acetate of aluminium and
applications of iodoform. I have tried the latter many
times without positive results. The best results which I
have seen have been mainly from free applications of a
mixture of glycerin and subnitrate of bismuth. Allow me
to narrate a typical case in which the results of this treat-
ment were quite a revelation to me :
A young unmarried woman came under my observation
with gonorrhoea in an intensely acute form. The urethra wa3
evidently involved, the mucous and submucous tissues of the
vagina were inflamed and infiltrated, and there was also inflam-
mation of the mucosa of the cervix. There was no question as
to the diagnosis, as the man with whom she had cohabited was
also suffering with gonorrhoea. Applications of sublimate,
eucalyptus, iodine tincture, etc., were tried for two or three
weeks without success. The patient was then informed that
she must give up her occupation (that of book-keeper), remain
in bed for a season, and receive such treatment as seemed ne-
cessary. A mixture of subnitrate of bismuth and glycerin was
at hand, and a tampon saturated with this was used empirically.
Two days later the fampon was removed, and, to my surprise,
the congestion and sensitiveness of the inflamed portions were
greatly modified, and the offensive discharge had greatly dimin-
ished. This treatment was, therefore, continued, with applica-
tions of iodoform, every day, and after a week every other
day, the tampon remaining ten or twelve hours. Vaginal
douches of hot water were also very carefully given once or
twice a day, after the removal of the tampon. Liquid food was
taken, and an abundance of alkaline drinks. In three weeks
every trace of the disease had disappeared, and the patient had
resumed her occupation.
I have frequently used the subnitrate of bismuth and
glycerin mixture since the experience described, and always
with satisfaction. Its function consists in a free depletion
of the congested tissues and a very decided astringent ac-
tion. The proportion of a drachm of bismuth to an ounce
of glycerin may be used, the mixture being, apparently,
Oct. 24, 1885.]
BRINKMAN:
VALVULAR ANEURYSM.
455
only a mechanical one. Such a mixture may not be direct-
ly destructive to gonococci, but, by the modifying action
which it has upon the secretions, it deprives them of the quali-
ties which are necessary to cultivation-fluids, and thus the
microbes die of starvation. Whatever method of treatment
is chosen, it must be carried out persistently and systematic-
ally, even to the last detail. It will not be enough to pre-
scribe vaginal injections or uterine applications of this or
that; the physician must be certain that they are used, and,
if necessary, must attend to or superintend the details him-
self. Especially is this true in regard to those obscure
forms of the disease which affect the glands and ducts of
the urethra, vulva, vestibule, and fourchette. Abscesses
and fistula? may be results of the disease in these parts, and,
in addition to the list of drugs for local application, it must
be borne in mind that it may be necessary to use the knife
or actual cautery before the disease can be overcome. Such
a course has been recommended by Guedeney, Martineau,
and Vidal de Cassis. If the given symptoms point to an
extension of the disease to the tubes and ovaries, the ques-
tion of abdominal section becomes a pertinent one. I be-
lieve that this operation is done too often. It is not suffi-
cient that an operator can show a good percentage of recov-
eries after salpingo-ovariotomy ; he must show positive
results flowing from the removal of important organs in
which, in many cases, no disease is traceable either by the
naked eye or the microscope. Many plans of treatment are
available before a woman should be submitted to the risks
and uncertainties of a capital operation. Concerning the
curability of the disease, Noeggerath's paper declared that
he did not think this possible, and I have seen no statement
from him to the contrary, though Neisser's doctrine was
announced seven years after the first publication of that pa-
per, and may have modified his views. Bumm believes that
it may be entirely recovered from, and that it is amenable
to treatment according as the area of infection is moderate
in extent and near the surface. Arnaud has observed that
it can be considered radically cured only when the menses
have become regular and when metrorrhagia and other
symptoms and complications have ceased (" L'Union med.
du Canada" [from " Abeille med."], May, 1885, p. 223).
This statement is unsatisfactory, however, for there are
many cases in which neither metrorrhagia nor any irregu-
larity of the menses occurs at any time. My own belief is
that it depends upon the gonococcus for its activity ; that if
the mucous membrane, with its innumerable crypts, follicles,
and glandules, is treated with sufficient thoroughness by
either of the efficient germicides which have been mentioned
for a sufficient length of time, which will vary with the ex-
tent of tissue involved and the potency of the secretions
which serve as cultivation-fluids for the gonococci — that if
these conditions are fulfilled the disease can be cured, for
dead organisms can not reproduce themselves. Of course,
this statement has no bearing upon the question of reinfec-
tion which, so far as I know, is at any time possible.
A few days ago I saw a lady who h'rst came to me more
than two years ago with gonorrhoea, which was very obsti-
nate and rebellious to treatment, For more than a year she
was almost constantly under observation, and at the end of
that period I considered her cured. Since then there have
been no clinical manifestations pointing to a recurrence of
the disease, therefore I see no reason why her cure should
not be considered positive, and I believe the same would
hold equally true in any similar case.
38 West Thirty-sixth Street.
VALVULAR ANEURYSM*
By ALBERT BRINKMAN, M. D.,
BROOKLYN.
The specimen I present is one of disease of the aortic
and mitral valves, accompanied by valvular aneurysm of one
of the leaflets of the mitral valve. The subject from whom
it was taken was a man of tall and muscular physique, who
entered my service at Charity Hospital, giving the following-
history :
John M., aged thirty-eight years, native of Ireland, and a
blacksmith by occupation, enters complaining of oedema of
both legs. Admits the abuse of alcohol, but denies all history
of rheumatism; to use his own words, if he ever had rheu-
matism he was not aware of it. No evidences of syphilis ob-
tainable. Two years ago he first noticed swelling of both ankles,
and that lie easily became short of breath on exertion. Apply-
ing to a dispensary, he obtained some medicine (presumably
digitalis), which caused the oedema to disappear. Within the
last few months the swelling has increased to such a degree as
to extend up both legs to. the knee joints.
Physical examination reveals an increased area of the apex
beat, which, on palpation, is found displaced to the left, and
downward on a line with the left nipple ; the beat is not dis-
tinct, but rather diffused. A murmur is heard, commencing
before and taking the place of the first sound of the heart. It
is a continuous murmur, which begins before the ventricular
systole and continues until the second sound of the heart; it
has its maximum intensity at the apex. This murmur, or (pre-
suming it to be a double one, mitral, obstructive, and regurgi-
tant) part of it, is conveyed to the left and heard behind.
At the base there is a murmur with both sounds of the
heart, or, as it is generally termed, a see-saw murmur. The
systolic portion is heard in the vessels of the neck.
Diagnosis. — Aortic obstruction and regurgitation ; mitral
obstruction and regurgitation.
Urine examined. Albumin found, but no casts.
Treatment. — Inf. digitalis, § ss., t. i. d., which caused great
diminution in the oedema, but also the development of digitalis
poisoning after one week's administration. The digitalis was
stopped for a few days, and ext. convallarisB maialis n\, gtt. xv,
t. i. d., substituted. In three weeks, the oedema growing worse,
he was again put on digitalis.
The patient died after being in hospital one month.
The autopsy showed a-greatly hypertrophied heart, the weight
of which, after its cavities were freed from blood, was twenty-
four ounces. This is a maximum weight for a heart with com-
bined aortic and mitral disease, a heart with both of these
lesions generally being intermediate in weight between that
which obtains in the two separate forms of the disease, the
organ being lighter than in aortic and heavier than in mitral
disease. Sibson gives cases of this kind in the male as averag-
ing from 1 4 § 83 to 21 3" 83. The extremes of mitral dis-
ease are 14 § to 18 § ; the extremes of aortic disease are 14 3
to 46i I , the latter being that of a case of aortic obstruction
mentioned by Bristow.
I * Read before the Brooklyn Pathological Society, May 14, 1858.
456
FOWLEti: H YD R UNA PH THOL ; A NEW ANTISEPTIC.
[N. Y. Med. Jouk.,
Upon opening the heart, contraction and thickening of the
aortic valves were found, with calcareous incrustations and vege-
tations. The mitral valve, besides being insufficient, shows a
valvular aneurysm of its posterior leaflet.
Sibson, in " Reynolds's System of Medicine," gives the
mode of development of these pouches, or aneurysms, as
follows. After speaking of the ordinary pathological lesions
found in mitral disease, he says : " Sometimes, however, the
inflammation deepens at its original seat on the surfaces of
contact of the mitral valves and extends beyond those sur-
faces, so as to affect a large portion of the flaps of the
valves on their ventricular surface. Under these circum-
stances the inflamed, softened, and thickened structure may
undergo granular degeneration, and its ventricular layer be-
come broken or ulcerated. The auricular layer of the valve
thus tends to yield before the pressure of the blood, which
forces its way through the breach into the ventricular layer,
and to form pouches or aneurysms protruding into the left
auricle." I may mention that the process may stop here, or,
as Sibson goes on to say, " the auricular layer may then be
involved in the inflammation, and become in turn subjected
to granular disintegration and breaking up of tissue, so that
the flap of the valve may become perforated." This has
been the case in the specimen before you, after the forma-
tion of the pouch perforation has occurred into the auricle.
Now, we know that the mitral valve is peculiarly liable
to these aneurysms — more so than the aortic valves. It is
comparatively seldom that we meet with them on the aortic
valves. This predisposition is readily accounted for if we
glance for a moment at the action of the mitral valve. " The
mitral valve is closed on exactly the same principle as the
aortic valve — namely, by the pressure of the blood, driven
during the ventricular systole into the small open cells on
the under or ventricular surface of the valve. The force
with which the blood presses upon the closed mitral valve,
the closure of which is caused by the contraction of the
ventricle, is much greater than the force with which the
blood presses upon the aortic valve, the closure of which is
caused by the recoil of the previously distended walls of
the aorta. The flaps of that valve — namely, the aortic —
are pressed together by the backward portion only of the
effect of the recoil of the aortic walls, which expends itself
in every direction ; and that force of recoil is itself but a
portion of the original propulsive force of the left ventri-
cle, which presses with its full power upon the closed mitral
valve. The surfaces or lines of contact or closure of the
mitral valve extend along and just within the borders of its
two flaps. This border of contact is not a mere edge, but
a surface or line of adaptation, made up of the small bead-
shaped cells that dovetail into each other along the margins
of the flaps; the result is that the margins of contact of the
mitral flaps press against each other, when the valve is closed,
with much greater force, tension, and concentration than
the margins of contact of the aortic valve."
Taking this view of the action of the mitral valve, it is
seen that this valve is subject to valvular aneurysm because
of the great amount of pressure brought to bear against it
in the ventricular systole, and also because endocarditis
does not attack the very edges of the mitral valve, but the
margin just within its edges ; and after an endocarditis has
occurred, with its production of new tissue, and this new
tissue undergoes fatty, granular, or calcareous changes, ul-
ceration sets in on the body of the valve ; this ulceration
either goes on to perforation, causing rupture of the valve
and consequent regurgitation, or the structure of the valve
becomes so attenuated that a portion of it yields to th
blood-pressure and forms a pouch or valvular aneurysm.
Again, the mitral valve, which is situated in the muscular
center of the ventricle, and in the focus of its internal in-
flammation, must be more prone to these aneurysms than
the aortic valve, which has broader surfaces of contact,
less pressure of blood, and no tendinous traction. To dem-
onstrate further that the pressure is greater against the
mitral than against the aortic valve, take a case of aortic
valvular aneurysm ; instead of the pouch protruding in the
direction of the aorta, the aneurysm protrudes downward
into the ventricle. Therefore, to cause these pouches to
protrude into the ventricle, the blood-pressure must be
greater on the aortic side of the valves than on the ven
tricular; but the pressure produced by the aortic recoil is
decidedly less than that caused by contraction of the ven
tricle, as I have before proved.
H YDRON APIITHOL ;
A NEW ANTISEPTIC.
By GEORGE R. FOWLER, M. D.,
SURGEON TO ST. MARY'S GENERAL HOSPITAL, BROOKLYN.
[Continued from page 404-)
At my request, Mr. Max Schwarz, of New York, Super-
intendent of the Technical School for Brewers, known as
" The First Station of the Art of Brewing," etc., and late a
pupil of Prof. F. Cohn, of Breslau, Germany, made the fol-
lowing experiments upon the antiseptic powers of hydro-
naphthol at his laboratory :
In the first instance the following incubation liquid wa
prepared, viz. :
Distilled water 1 litre ;
Chemically pure grape-sugar 100 grammes ;
Potassium phosphate 30 "
Ammonium nitrate 30 "
This was sterilized by boiling for thirty minutes.
This liquid was divided in ten equal parts as follows :
Part I, containing no hydronaphthol.
" II, " 1 part in 9,000 parts of the liquid.
" III, " 1 " 8,000 " " "
« jy5 « i « 7?000 « « «
it y, '0'-} 1 " 6,000 " " "
a Yl, " 1 " 5,000 " " "
u Y1I, " 1 " 4,000 " " "
" VIII, " 1 " 3,000 " " "
" IX, " 1 " 2,000 " '*r "
a x, " 1 " 1,000 " " "
Of each of these above-named liquids four equal parts
were incubated in the following sequence, after all had beer
sterilized by boiling beforehand, with the germs of the
following- fungi :
Oct. 24, 1885.]
FOWLER: H YD R ON A PHI TIOL ; A NEW ANTISEPTIC.
457
Penicillium glaucum,
Mucor mucedo,
Aspergillus niger,
Sterigraatocystis nidulans.
After incubation these culture-liquids, forty in number,
were placed in an air water-bath (incubator) which was kept
at a temperature of 24° C. for forty-eight hours. After the
lapse of this time a strong fungoid growth could be per-
ceived in all the control tests, which latter, of course, did
not contain any hydronapbthol, while all the liquids con-
taining hydronaphthol had remained clear and free from
fungoid growth, and remained so for more than five days,
when they were disposed of.
These experiments prove that hydronaphthol, in pro-
portion of 1 to 9,000, prevents the development of these
germs. Even more diluted solutions of hydronaphthol may
possess antiseptic action, but exact observations have yet to
be made in order to ascertain the limit of its antiseptic
power. This, of course, would be of highly scientific in-
terest, but for practical purposes the above given proportion
of 1 to 9,000 may be sufficient in all cases where inhibi-
tion of the germs of this class is desired.
A second series of investigations into the antiseptic prop-
erties of hydronaphthol was conducted as follows.
To each of the above-named solutions the compound
was added as follows :
1 part of hydronaphthol in 9,000 parts of the solution.
1 " " " " 8,000 " " "
Y it " " " " 000 " " "
1 " " " « 6,000 " " "
1 " " " " 5,000 " " "
1 " " " « 4,000 " " "
1 " " " " 3,000 " " "
1 " " " " 2,000 " " "
1 " " " " 1,000 " " "
and a control-test, free from hydronaphthol.
After careful sterilization by means of boiling, to these
were added three cubic centimetres of a suspension of the
best, purest, and healthiest beer-yeast (saccharomycis cere-
visice) ; these were well agitated, and then kept quiet for four
days, all being well protected from the germs floating in
the atmospheric air by closing the mouths of flasks contain-
ing these liquids with sterilized cotton-wool.
After four days' standing, about one tenth of each of
these liquids was distilled off separately, and the ten differ-
ent distillates tested for alcohol by addition of a solution of
iodine in a potassium-iodide solution rendered alkaline by
means of potassium hydrate.
After twenty-four hours' standing the precipitates thus
formed were examined under the microscope, and the fol-
lowing results obtained :
In the distillate of the solution containing no hydronaph-
thol, iodoform was found.
In the distillate of the solution containing
1 part hydronaphthol to 9,000, iodoform was found.
1 " " " 8,000, "
1 " « a 7)000) «
1 " " " 6,000, "
1 " " " 5,000,
1 part hydronaphthol to 4,000, iodoform was found.
1 " " " 3,000, " " "
1 " " " 2,000, no iodoform was found.
1 " " " 1,000, " " " "
From these experiments the conclusion is to be drawn
that 1 part of hydronaphthol dissolved in 2,000 parts of a
solution which, under ordinary circumstances, ferments
readily with yeast, is capable of holding in check this fer-
mentation. Microscopic examination showed that in the
liquids containing hydronaphthol in the proportions of 1 to
1,000 and 1 to 2,000, the yeast-cells presented the appear-
ances of a coagulated protoplasm, while those in the other
liquids showed a good and healthy protoplasm.
The foregoing experiments confirm the observations
made at the Johns Hopkins University laboratory concern-
ing the inhibitory antiseptic effect of this compound. The
hope that a positive germicide effect may yet be demon-
strated is suggested by the results of these observations and
the extremely dilute solutions found to be efficient in the
inhibiting of these organisms.
The following series of cases is herewith presented,
comprising my experience up to the present date, in the
practical application of hydronaphthol to surgical practice.
Some interesting points are worthy of mention, among
others the fact that the application of the powder directly
to the skin was not without some disadvantages, in that it
produced irritation, and in two cases, at least, was responsi-
ble for a failure to secure union by first intention. These
cases, however, continued to pursue an aseptic course.
When the hydronaphthol was diluted in a two-per-cent.
trituration with carbonate of magnesia, this feature was no
longer noticeable, and the value of the new antiseptic was
ully demonstrated.
Case I. — floating Body in Knee Joint. — Mrs. G., aged fifty-
six, for several years past has suffered from sudden pain in
knee joint, especially while ascending or descending a stairway.
This was followed frequently by an attack of synovitis. Re-
cently these attacks have recurred with increasing frequency,
and she became clamorous for relief. Examination revealed
the presence of a floating body in the joint. On September 14,
1885, I opened the joint, having failed in an attempt to fix the
body for the purpose of cutting down directly upon it. I passed
my finger into the interior and searched for and removed the
body. It proved to be of the shape and character usually found
under the;-e circumstances, and of about the size of a haze!-nut.
The joint was thoroughly irrigated with a warm solution of hy-
dronaphthol, 1 to 1,000, a few strands of catgut introduced for
purposes of drainage, the wound closed with a continuous cat-
gut suture, pure hydronaphthol dusted over the wound, a saw-
dust cushion which had been saturated in a hot alcoholic solu-
tion of hydronaphthol and then dried was then bandaged over
the wound, a well-padded back-splint applied, and the patient
placed in bed. No pain, fever, nor other untoward circumstance
occurred to give me any uneasiness in this, my first case of im-
portance in which the new antiseptic was used. At the end of
fourteen days I removed the dressings for the first time, Hexed
the limb at a right angle, and in a few days the patient was
walking about — well. There was an excoriated spot near the
line of union, which a subsequent experience led me to believe
that the hydronaphthol, applied as ii whs in its undiluted state,
was responsible for.
Case II. — Excision of Entire Bad his. — E. I., aged nii.e and a
458
FOWLER: HTDRONA PHTIIOL ; A NEW ANTISEPTIC.
[N. Y. Med. Joua,
half. Osteomyelitis of the left radius. Operation September
14th, at St. Mary's General Hospital. Incision entire length of
radius, upon outer and posterior aspect of arm. Bone sawed
through middle with chain-saw, and each half separated from
periosteum and removed. Hydronaphthol solution, 1 to 1,000,
used for irrigating; drainage-tube of soft rubber placed in posi-
tion ; sutures of catgut; pure hydronaphthol dusted along line
of sutures and wood-flour dressing applied. Dressings first
changed, on account of profuse discharge, on eighth day. Edges
of wound united at intervals, primary union taking place, per-
haps, in the aggregate, in about one half of the length of the in-
cision. The skin about the points where union had not taken
place was red, and in spots presented an excoriated appearance;
this latter being due, no doubt, to the pure hydronaphthol dust-
ed upon the edges of the cut surfaces. The wound was irrigated
as before and redressed, and healing thereafter proceeded with-
out interruption. No rise of temperature after third day.
Case III. — Wry Neck ; Open Section of Sterno-cleido Mas-
toid.— M. S., aged eight. Wry neck resulting from measles four
months ago. Sterno-cleido mastoid contractured. September
18th made section of the muscle, both at its clavicular and
sternal attachments; irrigated with hydronaphthol solution;
catgut drain and sutures. Dusted hydronaphthol and carbo-
nate of magnesia (two parts to one hundred) along line of inci-
sion ; dressed with wood-Hour sterilized with corrosive sublimate,
and rendered antiseptic by hydronaphthol. Head retained in
position by plaster-of-Paris dressing, including chest, shoulders,
and head. No fever, pain, nor other disturbance. Entire
dressing removed on twentieth day. Wound healed perfectly;
no pus.
Case IV. — Wood's Operation for Radical Cure of Hernia. —
E. M., aged fourteen. Inguinal hernia, left side, of several
years' standing. Has tried many trusses, but, owing to sensitive
skin and extremely nervous condition of child, were abandoned.
The parents solicited an operation for his relief. September
23d, operation of Mr. John Wood performed. Silver-wire
suture. Hydronaphthol solution, 1 to 1,000, used for irrigat-
ing. Wound in scrotum left open; dressings of wood-flour
and hydronaphthol applied. No fever nor other cause for
anxiety. Wire and last dressings removed on fifteenth day.
Needle punctures closed in twenty-four hours; wound in scro-
tum granulating in a healthy manner Ointment of hydronaph-
thol ( 3 ss. to §j) ordered for latter. Discharged, cured, on
twentieth day.
Case V. — Ligature of Femoral Artery for Elephantiasis. —
Mrs. C, aged forty-eight, admitted to hospital September 23d.
Elephantiasis arabum of both lower extremities below knee
joint of four years' duration. Patient an opium habitue.
Operation of ligature of femoral above profunda on September
24th. Irrigation by means of hydronaphthol solution, 1 to
1,000. Pure hydronaphthol sprinkled along line of sutures.
Wood-flour-cushion dressings and a spica bandage applied. No
fever, but dressings had to be removed on fourth day on ac-
count of profuse serous discharge. Skin along line of sutures
irritated and in some places excoriated. Union for about one
third of the length of wound only; deeper portions of wound
nnited. Dressed thereafter with an ointment of hydronaph-
thol ( 3 ss. to | j). Granulating healthily.
The limb was at first cold and of a yellowish gray color ; in
a few hours it became warm. In eight days it was found to
have been reduced in size fully one third. Case still under ob-
servation.
Case VI. — Strangulated Hernia ; Operation. — E. W., aged
seventeen. Eight inguinal hernia had existed for several years ;
for last two or threo years had worn no truss. Hernia had not i
been reduced completely for four months. Admitted to St. I
• Mary's General Hospital, September 24th. When seen by me
: was in acute general peritonitis, faecal vomiting, knees drawn up,
countenance drawn and anxious, pulse small and thready, sur-
i face cold and clammy. Symptoms of strangulation had existed
for six days prior to admission. Stimulated freely; three hours
later herniotomy performed ; sac opened ; gut believed to he yet
i in good condition, so far as could be ascertained. Large mass
, of omentum excised, and some portions adherent to canal were
i brought up and stitched with catgut to internal ring with neck
of the sac. Hydronaphthol, 1 to 1,000, used for irrigating, and
pure powdered hydronaphthol dusted along line of incision ;
wood-flour dressings applied. Patient rallied after vigorous
stimulation. Dressings removed on fourth day, owing to their
becoming disarranged by restlessness of patient. Deeper por-
tions of wound found to be healed. Integumentary margins
were found to have been irritated, swollen, and gaping. Su-
tures of catgut had softened by the copious exudation from the
wound edges, and had given way. Granulation went rapidly
on; peritonitis rapidly subsided ; bowels moved spontaneously
on the seventh day. Patient sat up on the twenty-first day.
The wound rapidly granulated under the application of hydro-
naphthol ointment ( 3 ss. to ^ j).
Case VII. — Perforating Wound of the Elbow Joint. — J. C,
aged eight. Upon the evening prior to applying at my office,
September 24th, while reaching up to unlatch an area-gate, his
foot slipped from the stone step, and his left arm was caught
upon one of the iron pickets of the gate. He called for assist-
ance, and his mother lifted him from the sharp iron rod upon
which he hung. A ragged wound was found upon the inner
border of his arm, near the posterior surface. A dressing of
vaseline was applied. The boy complained greatly of pain, and
the following morning he was brought to my office. The joint
was very much swollen, hot, and tender. Synovial fluid was
escaping from the wound. A probe, passed along the wound
track, entered the joint midway between the inner condyle of
the humerus and the olecranon process of the ulna. Pulse 130,
temperature 102|°. Wound surroundings and joint irrigated for
several minutes with warm solution of hydronaphthol, 1 to 1,000,
drainage-tube introduced, parts dusted with hydronaphthol and
magnesia (2 to 100). Paper-wool and hydronaphthol dressing
and trough-splint applied. In twenty-four hours temperature
reduced to 99° ; pulse to 80. Pain had entirely disappeared.
Dressings removed on the fourth day for the purpose of remov-
ing the drainage-tube; for this latter catgut drains were substi-
tuted. Arm was found to be normal in size and appearance.
On the fourteenth day following the injury the dressings were
again removed, when the wound was found to be healed, with
complete movement in the joint.
Case VIII. — Osteosarcoma of Tibia. — Mrs. M., aged fifty-
four. Blow upon middle third of left tibia about four months
prior to operation. Admitted to St. Mary's General Hospital,
October 2d. Large mass of broken-down sarcomatous growth
(fungous hasmatodes) upon anterior aspect of tibia, at about its
middle. Amputation at knee joint performed October 5th by
lateral-flap method. Hydronaphthol irrigation (1 to 1,000) ; rub-
ber drainage-tube; hydronaphthol and carbonate of magnesia
(2 per cent.) were well triturated together and dusted along
line of sutures. Dressings of wood-flour cushions applied. No
rise of temperature, pain, nor other inconvenience. Dressings
not disturbed until tenth day. Parts aseptic; drainage-tube
removed ; union perfect ; no irritation. Cushion of wood-flour
reapplied to small opening through which drainage-tube had
emerged.
Case IX.— Compound Fracture of Leg. — T. W., aged eight,
school-boy. Brought in by ambulance October 8th. Heavy
truck-wheel had passed over his left tibia and fibula at the junc-
Oct. 24, 1885.]
ROBERTS: COCAINE ANAESTHESIA IN OSTEOTOMY.
459
tion of the upper with the middle third. WouDd leading down
to fibula admitting- my index-finger; another over tibia, about
an inch and a half long. Surrounding parts and wound itself
thoroughly washed and deeper portions irrigated with hydro-
naphthol solution, 1 to 1,000. Several strands of catgut were
passed from bottom of each wound through the soft parts; hy-
dronaphtholated magnesia and wood-flour cushion dressings ap-
plied ; limb supported in a wire-cloth splint and suspended. No
pain since dressings were applied ; slight fever at end of first
twenty-four hours, which subsided in a few hours without any
treatment. Primary dressings still in situ at present writing
(October 19th, eleventh day), and these will not be disturbed,
unless some special indications exist, until bony union is believed
to have taken place.
Case X. — Supra-condyloid Osteotomy for Genu-varum. —
Rosie K., aged thirteen. Three months previously I performed
excision of the knee joint for tubercular osteitis of the inner
femoral condyle and head of tibia. Owing to extremely thin
shell of bone left after gouging out with Volkmann's sharp
spoon cancellous tissue of condyle and head of tibia, good ap-
position of the parts was not obtained, and, when the dressings
were finally removed, the limb was found to be in the position
of genu-varum. To correct this, a supra-condyloid osteotomy,
after the manner of Macewen, was done on October 8th at the
hospital. The incision, however, was made upon the outer in-
stead of the inner border of the thigh. Catgut drain inserted ;
wound sutured; hydronaphthol in carbonate of magnesia (2 per
cent.) dusted along line of sutures; wood-flour cushion dressing
and plaster-of-Paris splint applied. No fever, pain, nor dis-
charge has occurred up to present writing (October 19th). It
is not expected that the dressings will be removed in this case
until union of bone is believed to be complete.
Case XI. — Fibrous Tumor at Site of Pre-trochanteric Bursa.
— J. H., aged forty-seven, Egyptian sailor. Admitted to hos-
pital on account of growth over right trochanter. Fell from
rigging of vessel some years ago and received an injury to the
bursa in this region, which led to suppuration. Since then
there appeared the present growth, which has grown slowly,
and of late has occasioned him some inconvenience, and at
times been tender and painful. Operation of excision October
8th ; hydronaphthol solution, 1 to 1,000 for irrigation, etc. ; cat-
gut drains. Hydronaphtholated magnesia (2 per cent.) and
wood-flour cushion dressings held in position by spica. Dress-
ings found disarranged, and therefore changed on fourth day.
Union progressing along entire line of incision; no irritation or
discharge; case thus far afebrile and painless (eleventh day).
{To be continued.)
COCAINE ANAESTHESIA
IN
FEMORAL SUPRA-CONDYLOID OSTEOTOMY AND
EXCISION OF THE HIP JOINT*
By MILTON JOSIAH ROBERTS, M. D.,
PROFESSOR OF ORTHOPAEDIC ST7RGERY AND MECHANICAL THERAPEUTICS IN
THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ; VISIT-
ING ORTHOPEDIC SURGEON TO THE CITY HOSPITALS ON RANDALL'S ISLAND,
ETC.
The temporary character of the local anaesthetic effect
of cocaine, thanks to the brilliant suggestion of Dr. Cor-
ning, f is a thing of the past. It is now possible to prolong
* Reported to the Clinical Society of the New York Post-Graduate
Medical School and Hospital, October 17, 1885.
t " On the Prolongation of the Anajsthetic Effects of the Hydro-
chlorate of Cocaine when Subcutaneously Injected. An Experimental
this effect of the drug to any desired extent by simply
obstructing the circulation of the blood through the tissues
into which it is injected, thus effectually preventing its es-
cape from the area desired to be rendered anaesthetic.
In the "Medical Record" of this date, October 17th,
will be found a communication from me on cocaine in bone
surgery, with a description of my first operation. I now
desire to report two additional operations performed, under
cocaine anaesthesia, this afternoon. These operations were
both performed in one of the Randall's Island hospitals,
and one or both of them witnessed by Dr. James R. Healey,
Dr. E. L. Cocks, Dr. G. H. Cocks, Dr. C. C. Bradley, Dr.
Stephen Vittum, Dr. O. C. Tarbox, Dr. M. J. Rockwell,
Dr. G. D. Wheat, and Dr. R. Lewis, the six last-named gen-
tlemen composing the house staff and assisting in the opera-
tions.
Before describing the operations in detail, however, I
may remark that they were undertaken with the idea of
making a crucial test of the efficacy of the method of local
anaesthetization employed. Just what advantages this par-
ticular method possesses, and the determination of the range
of its practicable applicability, are questions which can not
be satisfactorily answered by the results obtained in a few
experimental operations. It is possible, nevertheless, by the
elimination of obvious sources of error, to determine the
probable extent, profundity, durability, and regularity in the
production of the local anaesthetic effects of the drug.
My first operation, above referred to, was for elbow-joint
disease. It involved, in addition to the extensive division
of soft tissues, the excavation of the entire inner condyle of
the humerus and part of its outer condyle. Though a small
drill-hole was made transversely through the upper end of
the ulna, which bone, upon microscopical examination of the
debris thus removed, was ascertained to be in a healthy con-
dition, the main part of the operation was confined to the
removal of diseased bone, and therefore the parts divided
might not have been possessed of their normal degree of
sensitiveness. This source of error, as will appear, does not
require to be considered in the operations now to be reported
upon. Again, my first patient, though a delicate female in
an exceedingly apprehensive frame of mind, was an adult.
The question arose, Was the method also applicable to opera-
tions on children? Then, too, there was the question of fear
and mental excitement, which forced itself into recognition,
when considering the possible causes of the manifest absence
of pain during the operation.
Femoral Supra-condyloid Osteotomy for Genu Valgum.
— The first operation which I have to report was performed
upon a boy about four years of age. Some months ago,
the patient being aetherized, I did four cuneiform osteoto-
mies upon the bones of his legs in their lower third for
the correction of anterior curvatures. There remained
marked genu valgum of the left limb. When placed upon
the operating-table on this occasion, the little fellow showed
some signs of fear. Applying a fine needle, half an inch in
length, to a hypodermic syringe containing a freshly made
five-per cent, solution of cocaine (Merck's), I made super-
Study." By J. Leonard Corning, M. D. " New York Medical Journal,"
September 19, 1885.
460
BOOK NOTICES.
[N. Y. Mkd. Joijb.,
ficial injections over the inner anterior aspect of the thigh
just above the knee. The successive injections, for the
most part, were made into the periphery of the area of red-
ness (ischaemia) resulting from previous injections. When-
ever this rule was deviated from the child would wince and
complain of pain, though he did not cry out. For the pur-
pose of anaesthetizing the deeper tissues, the short needle
was replaced by one an inch long and the injections were
continued. Having secured anaesthesia along the line of
Macewen's incision, an Esmarch's bandage was applied from
the toes up to the knee joint, where it was fastened. A
second Esmarch's bandage was continued from this point
up the limb to about five inches above the joint. Here the
thigh was encircled by a strong elastic band, and the Es-
march's bandage last applied removed, exposing that seg-
ment of the limb to be operated upon. The bandage first
applied was left in position throughout the operation. Three
or four injections down to the bone were made along the pro-
posed line of incision. The knife was now carried down to
the bone along the same line, making an incision two inches
and a half long. The child made no complaint whatever. In-
troducing the needle of the syringe through the wound thus
made I injected six or eight minims under the periosteum
and into the tissues above (in front) and below (behind) the
bone, in order that the passage of my retractors between the
bone and soft parts, as well as the subsequent section of
bone, might be rendered painless. Upon my attempting to
introduce the retractor, the child evinced discomfort when I
reached the outer aspect of the bone. I immediately with-
drew the retractor and injected about four minims down to
the bone and under the periosteum, on the outer aspect of
the thigh. This enabled me to proceed with the introduc-
tion of the retractors without complaint on the part of my
little patient. The retractors being introduced and the soft
tissues drawn back, freely exposing the bone, I quickly
removed a cuneiform segment from the femur just above
the epiphysis, by means of my electro-osteotome. Again
no pain was manifested by the child. The Esmarch's band-
age and elastic girdle about the thigh were removed, the
wound was closed and covered with antiseptic dressing, and
the limb brought into line and secured in position by means
of a gutta-percha splint. During this latter procedure and
the first punctures of the hypodermic needle the child com-
plained slightly of pain. At all other times during the
operation he manifested no discomfort. He was laid upon
a cot near by and watched the subsequent operation with
apparent delight, for whenever I looked at him he smiled
pleasantly, and, when questioned, answered cheerfully. In
this operation three grains of cocaine were injected.
Excision of the Hip Joint. — Encouraged by the results
thus obtained in the cocainization of bone and overlying soft
tissues, I proceeded at once to try the efficacy of local anaes-
thesia in excision of the hip joint, there being a patient in
the ward awaiting this operation. The subject of the sec-
ond experimental operation was a girl about six years old
who had suffered from hip disease for many months. An
abscess, the result of the morbid process going on in the
bone, had opened spontaneously and was discharging its
pus through a fistulous opening.
The superficial and deep structures were cocainized in
the same manner as before, a two-and-a-half inch needle be-
ing used for the deepest injections. I had not proceeded
far when I was informed that my supply of cocaine was
exhausted. A messenger was immediately sent for more
cocaine solution, but could only procure a four-per-cent.
solution which had been made up several days. With this
I continued the injection until I had apparently secured
profound anaesthesia along the intended line of incision. A
strong elastic band was tied about the proximal end of the
thigh. With his fingers placed under it on the outer
aspect of the limb, an assistant stretched this band and
drew it upward over the crest of the ilium. The pressure
thus produced was sufficient to interfere with the superficial
circulation. No means were at hand for compressing the
abdominal aorta. The usual incision for exsection of the
joint was made down to the bone. The patient complained
considerably of pain, but did not cry out. Cocaine was in-
jected through the wound into the tissues about the upper
end of the bone. Injections were also made into or under
the periosteum. The venous haemorrhage was considerable,
and seemed to wash the cocaine out of the tissues into which
it had been injected. On this account, or in consequence of
being obliged to use a weaker solution, and one not freshly
made, the anaesthesia was not so profound or so enduring as
in the previous operation. A longitudinal incision through
the periosteum did not cause the patient any pain, but, when
the periosteum was peeled off from the bone, the pain experi-
enced was considerable. Section of the bone below the
great trochanter with the electro-osteotome was without
pain. Upon removal of the bone, the head and most of the
neck of the femur were found to have been destroyed by
disease. The acetabulum did not appear to be involved.
The wound was closed with strong catgut sutures, drainage-
tubes having been previously introduced, antiseptic dress-
ings were placed over the line of suture, and a gutta-percha
splint was molded to the contour of the limb and body, and
allowed to harden.
105 Madison Avenue.
gooh Notices.
Minor Surgical Gynecology. A Treatise of Uterine Diagnosis
and the Lesser Technicalities of Gynaecological Practice, in-
cluding General Rules for Gynaecological Operations and the
Operations for Lacerated Cervix and Perinaeum and Pro-
lapsus of Uterus and Vagina, for the Use of the Advanced
Student and General Practitioner. By Paul F. Munde,
M. D., Professor of Gynaecology at the New York Polyclinic
and at Dartmouth College, Gynaecologist to Mount Sinai
Hospital, etc. Second Edition, Revised and Enlarged, with
three hundred and twenty-one illustrations. New York:
William Wood & Co., 1885. Pp. xxii-552.
{First Notice.)
We are glad to welcome a second edition of this excellent
book, which now appears in a form more worthy of it. The
author was very happy in the original idea of his manual, since
Oct. 24, 1885.]
BOOK NOTICES.
461
he wisely confined himself to just those minor technicalities
wbich had been previously described in a most imperfect man-
ner by tbe writers of more ambitious treatises. The real prac-
tical value of the book was at once apparent on comparing it
with even such manuals as Chrobak's. It was, in a word, the
difference between pure didactic construction and object-les-
sons. Not to dwell at length upon the reasons for the popu-
larity attained by Dr. Munde's work on its first appearance, it
will be safe to assume that the present edition possesses addi-
tional claims to the reader's esteem. Part III is entirely new,
while Part I and Part II have been carefully revised, and con-
tain a considerable amount of fresh matter and several new
illustrations. " Many cuts of instruments," as is aptly stated
in the preface, "have been omitted for aesthetic reasons." It
will be impossible, in the brief space allotted to us, to review
critically the minor improvements of the new edition ; but a
glance at the more important points will serve to indicate the
general scope of the volume.
In the section on the vaginal touch several new paragraphs
will be noted, while Figs. 14 to 20, inclusive, have been added.
Figs. 21 to 28, inclusive, also bear the author's initials, and
are worthy of commendation. Pages 66 and 67, which de-
scribe the disinfection of instruments, contain most valuable
advice with regard to an important subject which is too often
overlooked by general practitioners, and, indeed, by not a few
specialists, who are either too careless or too "conservative"
to employ the simple precautions here given. One thing is
certain : there would be a far smaller number of unfortunate re-
sults following gynaecological manipulations if the routine prac-
tice suggested by Dr. Munde was more general. The omission
of the usual confusing array of specula will be remarked as a
decided improvement, while the additions to the section on
holding the speculum (pages 85 to 91), including the excellent
illustration (Fig. 45), must render the subject perfectly clear
even to one who had never seen Sims's instrument in use — a
condition of ignorance which is happily rare in these days of
post-graduate instruction. Among the new paragraphs in the
section which describe the use of the sound we note with ap-
proval the author's emphatic statement that this instrument is
to be used to confirm, and not as a substitute for, the bimanual
examination. Due stress is laid upon the dangers and contra-
indications. Traction upon the uterus is deservedly reprehended
as a pure diagnostic aid.
Part II, including pages 127 to 409, has received a thorough
revision, but the interpolations are only apparent after a careful
comparison of the two editions page by page. There are sev-
eral new illustrations, some of which it must be confessed are
not so clear as they might be (see page 220). The process of
dilating the cervical canal, both by the bloodless method and by
discission, is thoroughly described, and the advantages and dis-
advantages of each are fairly stated. The long and valuable
section on pessaries has not been essentially altered. There are
still rather too many illustrations for practical use.
Part III, on Gynaecological Operations," being the new
portion of the book, merits a careful examination. Under the
head of " General Considerations " the author discusses the time
of operating, the treatment of patients before and after opera-
tions, and the different varieties of sutures, disinfection, and
anaesthetics. These pages will be of great value to the inexpe-
rienced operator, since they furnish just that information which
his le>s fortunate predecessors have been able to acquire only
by a long apprenticeship. Although no new facts are brought
forward, the old ones are arranged in a compact, yet most read-
able, form. Nearly fifty pages are devoted to the operation of
trachelorrhaphy, so that we are safe in assuming that the sub-
ject has been treated exhaustively. This otherwise excellent
chapter is marred by the presence of a number of cuts which
rather suggest, than actually illustrate, the conditions which
they are intended to portray. To the experienced reader they
are sufficiently clear, but, as works of art, Figs. 233 to 244,
inclusive, are not lovely to look upon. The fault certainly does
not lie with either the author or the artist, and the former
deserves praise for his attempt to emancipate himself from the
custom of copying the old cuts that have gone the rounds of all
the text-books.
The Climate of Canada, and its Relations to Life and Health.
By W. H. Hingston, M. D., D. C. L., L. R. C. S. Edin., etc.
Montreal: Dawson Brothers, 1884. Pp.266.
The author gives us, in this scholarly production, the result
of many years' interest in and study of the climate of Canada.
The nucleus for his essay was a discourse delivered before the
Natural History Society of Montreal several years ago. Thi
has been added to from time to time as relevant material came
to hand, resulting in a book which retains the familiar collo-
quial style, and contains considerable matter which would not,
perhaps, have appeared in a complete homogeneous essay on
the subject, which Dr. Hingston expressly states this is not.
He has succeeded, however — in the chapters on Climate proper,
the Relations of this Climate to Health and Life, and on the
Habits of the People — in giving us much new and valuable in-
formation about the country.
A short Introduction is given for the benefit of those who
are not familiar with the constituents of climate and their effects
on the human economy.
We learn from a study of Part I that, while there is great
variety in different regions of the country, the climate as a
whole may be set down as belonging to the dry, stimulating
class — one especially adapted for a residence to those with a
tendency to consumption, or in whom early signs of pulmonary
disease have already developed.
On turning to Part II to obtain the author's opinion of the
effect of the climate on mortality and disease (for statistical in-
formation is scant), we fall upon the opinions of an enthusiastic
friend to whose sensation beat is never so hot, or cold so cold,
in Canada as anywhere else, and by whom any deterioration in
the people, or relatively great mortality (as in young children),
is charged entirely to the habits of the people themselves. Un-
fortunately, as we have said above, accurate statistical informa-
tion is wanting even of causes of death, except that which is
furnished by the surgeons at the army stations, which makes a
very favorable exhibit compared with that of the British sta-
tions. Fevers are, as a rule, mild, especially those of malarial
origin. In regard to consumption, the army statistics support
the modern theory of the superiority of a cold, dry climate
over a warm, moist one for those predisposed to it, showing
that Bermuda has 8-9 cases of it to 1,000 of mean strength of
the army there, while Canada has only 5-6. According to the
author's experience, affections of the skin are less frequent here
than elsewhere; cataract is more common, but, nevertheless,
blindness much less frequent. Scrofulous inflammation, so com-
mon a cause of blindness in Europe, is rare here. Blindness in
Canada is commonly caused by small-pox, cataract, or injury-
Contagious diseases — such as small-pox, measles, and whooping,
cough — are more common than in Europe, especially in winter,
when fuel is saved at the expense of ventilation. In the whole
of Canada the proportion of the insane is one to seven hundred
and twenty. In speaking of seasons, Dr. Hingston notices that
the mortality commonly diminishes with the temperature, and
that the colder parts of the country are in reality the more
wholesome. The closing chapter — on the habits of the peo-
ple in regard to eating, drinking, clothing, etc. — shows such a
462
CORRESPOND EX CE.
[N. Y. Med. Jodh.,
bad condition of things, in the author's judgment, that it is cer-
tainly wonderful he is still able to maintain, as he does, that
there is no evident deterioration of the European physique in
Canada. At least a table of contents, but, better, a table of
contents and index, should he added to another edition.
Clinical Lectures on Scrofulous Neck. By T. Clifford All-
butt, M. A., M. D. Cantab., F. R. S., F. R. C. P. And on
The Surgery of Scrofulous Glands. By T. Pridgin Teale,
M. A., M. B. Oxon., F. R. C. S. London : J. & A. Churchill,
1885. Pp. 32.
These two clinical lectures on scrofulous glands of the neck
— one by a well-known physician, the other by a practical sur-
geon, the one treating of their cause and dangers to health, the
other dealing with their surgical treatment — are well worthy of
careful study. Dr. All butt insists upon the secondary nature of
the enlargement of these glands of the neck, and considers that,
in the vast majority of cases, the irritation, which is the cause,
has its starting-point in a pathological condition of the mucous
membrane of the pharynx, nose, or ear ; that when once this
increase in the size of the glands begins it is apt to go on to
caseation, and adhesions form between the capsule and the
gland, and also between the former and the surrounding tissues
of the neck, terminating in the formation of an abscess; that,
when once suppuration has taken place, it will undermine and
perforate the skin and leave sinuses, which will continue to
discharge until the diseased gland has been entirely eradicated.
He is very skeptical in regard to the spontaneous subsidence
of these swellings, if the gland has attained much increase in
size, as caseous matter has in all probability formed, and sup-
puration will take place. Medical treatment is of little use.
When, however, the enlargement is not great and caseation has
not taken place, much can be done by general constitutional
treatment and a residence by the sea. He considers that after
one is satisfied that cheesy matter has formed, the time for sur-
gical interference has been reached, and that extirpation of the
diseased gland or glands is called for.
Mr. Teale in his portion of the book treats of the surgical
management of these enlarged glands. He advocates their re-
moval by cutting down upon the gland and shelling it out of its
capsule, if the latter has not become incorporated with the
gland, and if the former has not become entirely degenerated.
For, if this state has been reached, suppuration is almost in-
evitable, the skin will become undermined, sinuses form, there
is great danger of other glands becoming involved, and disfigur-
ing scars result. When abscesses have formed he advocates
enucleating the diseased gland with a "spoon" and scraping
the sinus. By these means the cause of the abscess is removed
if pus has not formed, and, if suppuration has taken place, limits
its duration and amount. In the former case the scar left after
the operation is represented by a line, and in the latter case is
much less noticeable than where the suppuration has been al-
lowed to go on.
The volume is a practical and useful one, and should be gen-
erally read.
BOOKS AND PAMPHLETS RECEIVED.
A Text-Book of Pharmacology, Therapeutics, and Materia
Medica. By T. Lauder Brunton, M.D., D. Sc., F. R. S., F. R.
C. P., Assistant Physician and Lecturer on Materia Medica at
St. Bartholomew's Hospital, etc. Adapted to the United States
Pharmacopoeia by Francis H. Williams, M. D., Boston. Phila-
delphia: Lea Brothers & Co. Pp. 1035.
A Text-Book of Medical Chemistry, for Medical and Phar-
maceutical Students and Practitioners. By Elias M. Bartley,
M. D., Adjunct Professor of Chemistry, etc., in Long Island Col-
lege Hospital, etc. With Forty Illustrations. Philadelphia: P.
Blakiston, Son, & Co., 1885. Pp. 376. [Price, $2.50.J
Milk Analysis and Infant Feeding. A Practical Treatise on
the Examination of Human and Cows' Milk, Cream, Condensed
Milk, etc., and Directions as to the Diet of Young Infants. By
Arthur V. Meigs, M. D., Physician to the Pennsylvania Hospi-
tal and to the Children's Hospital, etc. Philadelphia: P. Blakis-
ton, Son, & Co., 1885. Pp. 102. [Price, $1.]
De l'emploi du chlorhydrate de cocaine dans le traiternent
de la coqueluche. Par le Docteur Moncorvo, professeur de cli-
nique des maladies de l'enfance a la Policlinique de Rio de Janei-
ro, etc. [Extrait de "1'Uniao Medica."]
Correspottoentc.
LETTER FROM WASHINGTON.
The Coming Meeting of the American Public Health Associa tion.
— Sanitary Inspection on the Canadian Border.
Washington, October 20, 1885.
Arrangements are being made for the meeting of the Ameri-
can Public Health Association, to be held here in December next. '
It is thought that by the earlier date of the meetings heretofore
held much of the influence that would otherwise have been ex-
tended to legislative circles has been dissipated, but that a meet-
ing during the opening week of the session of Congress, when
the members are all here, will be much more effective in secur-
ing such legislation as is thought necessary. Dr. Toner and the I
health officer called on the President this week, and, it is said,
secured from him a promise that he would be present at the
opening exercises of the association. The "Conference" of
health officers will take place at some time during the meeting,
and, as they are the ones directly interested in the practical
execution of State and local health laws, they naturally exert
a much greater influence upon Congress than the association
itself.
The revival of the Quarantine Act of 1878 has given the
Government the only authority it has had in the management of
national quarantine, since the expiration by limitation of the act
of June 2, 1879, which substituted the National Board of Health
for the Surgeon-General of the Marine-Hospital Service. Under
the act mentioned it is possible to have a pretty strict land or
sea quarantine at any place where the States have made no pro-
vision for it. There is now an inspection service organized
along the Canadian frontier which will no doubt prove equal to
the emergency. Michigan and New Hampshire are managing
theirown inspections — all, however, in harmony with the Marine-
Hospital Service — but the States of Vermont, Maine, Massachu-
setts, and New York, through their respective governors, asked
the Government to establish the service. Surgeon II. W. Austin,
of the Marine-Hospital Service, has had immediate charge of the
work on the frontier. The inspections, however, were appar-
ently begun too late to insure absolute safety, although great
good is done by the systematic vaccinations now for the first
time imposed on travelers crossing our Northern border.
Work is progressing on the new Medical Library building
foundations ; the excavation is complete and the concrete is
being filled into the trenches preparatory to laying the stone-
work. .
A meeting of the local Committee of Arrangements of the
International Medical Congress was held at Dr. Garnett's office
last week. Nothing transpired of public interest.
Oct. 24, 1885.]
LEADING ARTICLES.
463
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by . Edited by
D Appleton & Co. Frank P. Poster, M. D.
NEW YORK, SATURDAY, OCTOBER 24, 1885.
THE GOVERNOR OF NEW YORK AND THE STATE BOARD
OF HEALTH.
We lately charged that the Governor of the State of New
York was directly responsible for the attitude that we pre-
sumed the State would be obliged to take in asking aid from
the General Government in the task of preventing an extension
of the Canadian small-pox epidemic over the border. It has
now transpired that such aid has been asked for by the State,
and therefore the State is now depending upon the General
Government to do for it what it would have been amply able
to do for itself, but for the Governor's action in vetoing the
appropriation of the moderate sum of fifteen thousand dollars
made by the Legislature for the use of the State Board of
Health.
Some of the newspapers, recognizing the awkwardness of
the situation, have endeavored to palliate the Governor's course
by making it appear that he simply vetoed an appropriation in-
tended to cover a deficiency, that he pursued that course in
consequence of his having discovered that there was really no
such deficiency as had been alleged, and that the current im-
pression concerning the veto is the result of misrepresentation.
In answer to all this, we have simply to remark that, long
before the Legislature took any action in the matter, a docu-
ment signed by all the members of the State Board of Health
was submitted to Mr. Hill, setting forth the financial needs of
the board in the following terms :
" As will be seen by reference to the report of the Executive and
Finance Committee, the expenses of the board during the past fiscal
year have exceeded the amount of its appropriation, the sum voted by
the Legislature for the prosecution of its work being but $20,000,
while the actual expenditures foot up to $21,971.36. Fortunately, an
unexpended balance to its credit at the beginning of its last fiscal year
enabled the board to discharge its obligations without incurring indebt-
edness ; but the large growth of its registration work and the unprece-
dented demand for its engineering and sanitary counsel warn the board
of threatened financial embarrassment during the coming year unless
the $20,000 granted by the last Legislature for the continuance of its
work is supplemented by a suitable subsidy in the supply bill. Urgent
appeals are frequently received from local boards of health and citizens
of various parts of the State for advice and assistance in questions
of supreme moment to public health, requiring for their elucidation
skilled sanitary inspection and often exact analytical examination. As
far as the pecuniary resources of the State Board have permitted,
prompt response has been made to such appeals ; but, as they increase
in number, lack of means compels reluctant neglect of some of thetn.
Furthermore, under the duties imposed upon the board, to ' make in-
quiries In respect to the causes of disease, and especially of epidemics,
and investigate the sources of mortality, and the effects of localities,
employments, and other conditions upon the public health,' it is evident
that a system of sanitary investigation was contemplated far beyond
the present possibility of attainment, but absolutely needful to enable
it to take ' cognizance of the interests of health and life among the
people of the State.' Toward the fulfillment of these, the most im-
portant duties of the board, the sum of $15,000 is asked, and even
with this, in view of a threatened epidemic visitation, the demands
upon the board during the coming year will probably exceed its powers
of compliance. The regular appropriation of $20,000 barely suffices to
defray the expenses incident to the reception, recording, filing, and in-
dexing of the State vital statistics at the central office, together with
the voluminous correspondence necessitated by the wide range of ques
tions constantly referred for reply."
It was in consideration of these facts that the appropriation
was asked for, and the document from which we have quoted
was transmitted by the Governor to the Legislature. The Ways
and Means Committee granted the $15,000 asked for, and it was
the committee's wording — not the Board of Health's — that
made the item in the Supply Bill read for "deficiency." But
the fact that the word "deficiency" did so appear now serves
as the technical quibble on which the veto is sought to be justi-
fied ; because, forsooth, the Comptroller's books do not show
any balance on the wrong side of the account. Of course, the
Comptroller will not pay anything in excess of the sum actually
in his hands, so that there can never be a "deficiency" shown
on his ledgers. It is puerile, therefore, for the Governor's
apologists to urge that the State Board of Health asked for an
appropriation to cover a deficiency, and that the non-existence
of any deficiency was the Governor's reason for vetoing the
bill. The Governor knew perfectly well at the time that he was
depriving the board of money which it sorely needed to enable
it to carry on the work that it was its duty to carry on ; he
knew, too, that, if the board had had a million dollars at its dis-
posal, it could not legally spend more than $5,000 in any one
year for sanitary inspection. When we add to this restriction
the fact that another veto — that of the appropriation for the
State survey — has deprived the Board of Health of the gratui-
tous services of Mr. Gardner, who, as director of the survey, was
ex-qfficio a member of the board, in consequence of which the
board has had to set apart $3,000 out of its $5,000 for engi-
neering work imposed upon it in various acts passed by the last
Legislature — when we take these facts into consideration, the
full measure of Mr. Hill's blow at sanitation may be imagined.
THE PROPOSED NEW NATIONAL MEDICAL SOCIETY.
The plan of which we gave an outline some weeks ago, be-
ing that of a correspondent who had devoted a good deal of
thought to the subject, and had found that it commended itself
to a number of the leading members of the profession before
whom he had laid it, has been favorably spoken of by several
of our contemporaries, some of which have suggested modifica-
tions that are certainly worthy of consideration.
One of the suggestions thus brought forward is to the effbet
that an excellent society might be formed by the simple amal-
gamation of the various national special societies that now exist.
The obvious objection to this is, that the general practitioners
would not be represented, and it is undeniable that they include,
464
MINOR PARAGRAPHS.
[N. Y. Med. JorR.,
and always will include, a large proportion of the strong men
of the profession. Except for work in a special line, no organi-
zation that leaves out the general practitioner can become of
much consequence to the profession as a whole. We doubt if
the suggestion was seriously intended, but it is one that has
been made before, and therefore is worthy of notice, although,
we think, only to be rejected.
The " Medical Record " approves of our correspondent's
plan in the main, but thinks that, unmodified, it would not be
sufficiently " democratic." We presume that by this our con-
temporary means that it would not be representative in the
geographical sense. Our own idea is that it ought not to be.
A strictly regional representation is of consequence only where
legislation is involved, and the less legislation the new society
attempts, or is designed to attempt, the better. We are just
now suffering from too much legislation. Does any one sup-
pose that the Royal Society and the French Academy fail to
"represent" the learning and the culture of Great Britain and
France ? Yet the geographical notion, we fancy, would be
scouted by both of them. The " deestrick " system has never
yet led to anything very high-minded.
Nevertheless, the geographical idea may prove tolerable in
this instance, provided it is hedged about by certain safeguards,
and, if it should prove to be dear to the great majority of
American physicians, we should not oppose it; neither, we sup-
pose, would our correspondent.
MINOR PARAGRAPHS.
INTERNATIONAL COLLECTIVE INVESTIGATION.
We have received a very carefully prepared pamphlet de-
signed for the guidance of individual observers in the work of
the collective investigation of disease set on foot at the last
meeting of the International Medical Congress. The pamphlet
deals with rickets, acute rheumatism, chorea, cancer, and uri-
nary calculus, and contains blank forms, which those wTho re-
ceive them are asked to fill out and return to Dr. Jacobi, one of
the American members of the Congress's committee on the sub-
ject, the other being Dr. N. S. Davis.
The pamphlet is interesting in itself, and doubly interesting
as suggesting the query, How can the undisputed holder of an
official position under the Congress— and Dr. Jacobi is undoubt-
edly to be so reckoned — be looked upon as having been ineligi-
ble to any office the committee charged with organizing the
ninth Congress saw fit to confer upon him ? Yet that is pre-
cisely the illogical position that the New Orleans meeting of the
American Medical Association took when it virtually instructed
its enlarged committee to displace him from the organization as
it then stood.
AN " INDORSEMENT " OFFERED FOR SALE.
In another column we publish a letter from Dr. W. Oliver
Moore, calling attention to an injustice that certain competing
pharmacists have practiced toward Messrs. Mariani & Co. in
"pirating" published records of the successful use of the Mari-
ani preparations of coca, and at the same time craftily makiug
those records appear to apply to their own preparations. It is
very much to be regretted that a house that has been so punc-
tilious in avoiding even the semblance of any offense against
the courtesy of trade should have been treated in this shabby
way by some rival manufacturers. It is still more to be re-
gretted, however, that a member of our own profession should
have shown such a willingness to exchange his "indorsement"
of the Vin Mariani for money, as is apparent in a letter lately
received by Messrs. Mariani & Co., from which we quote as
follows :
"Will you kindly favor me with four (4) copies of your essay on
' Erythroxylon Coca,' and oblige ? If you will refer to the ' Med. Rec-
ord' for , advertising page vi, you will see me quoted by
& Co. for indorsement of fl. ext. coca. That is indeed a very
good preparation, but your Vin Mariani is very fine. If we have the
cholera, I should give it as a leading tonic. If my indorsement, oh the
first uxer of coca in the U. S., will advantage you any for advertising
purposes, I will furnish it to you for $25. If, also, you will honor me
with some samples of your Pate Mariani, you will oblige."
It is consolatory to know that the firm in question looked
upon this bit of impudence as quite phenomenal. We would
advise this "first user of coca" to keep on using it — upon him-
self— in the hope of ultimately raising himself above pseudo-
scientitic mendicancy.
THE PENNSYLVANIA STATE BOARD OF HEALTH.
The State of Pennsylvania has been somewhat tardy in es-
tablishing a State board of health, but perhaps she has only been
making haste slowly. Quite likely, this fact has not been alto-
gether to her disadvantage. At all events, she has constituted her
first board, as we learn by a recently published "Address of the
State Board of Health and Vital Statistics of the Commonwealth
of Pennsylvania to the People of Pennsylvania," almost entirely
of medical men, the single exception being that one member of
the board is an engineer. We at once recognize the value of an
engineer in the board, but we have always been at a loss to esti-
mate the precise advantage of having broken-down "states-
men "or political "workers" in such positions. The board's
"Address," to which we have alluded, is a remarkably simple
and cogent exhortation to the people of the State to further the
work of the board in their own behalf, quite free from the cant
that so often figures in such documents. It must be said that
the new board seems to be entering upon its work in a most
commendable spirit, and we wish it the fullest measure of suc-
cess.
THE PROFESSION OVER-CROWDED ABROAD.
Much having been written about the over-crowding of the
ranks of the medical profession in this country, some dreary
consolation may be drawn from the state of things that is rep-
resented to prevail in at least two foreign countries, one of
which is even newer than our own. It seems from a recent ar-
ticle in the "Lancet" that the repletion of the ranks has lately
been made the subject of serious inquiry by a medical society in
Belgium. It appears that certain "specialists" are allowed to
practice in that country without having taken a medical degree,
and the complaint is made that the preliminary examination is
not severe enough.
The other country referred to is Australia, from which a
member of the British Medical Association writes a long letter
to the "British Medical Journal," complaining of the enormous
difficulties in the way of success in practice. He says that at
Ballarat there are more medical men to-day than there were
when the population was greater by fifteen hundred.
NEWS ITEMS, ETC.
The New York Obstetrical Society.— At the annual meet-
ing, held October 20th, officers were elected as follows: Dr.
Paul F. Munde, president; Dr. H. T. Hanks, first vice-presi-
dent; Dr. Louis A. Rodenstein, second vice-president; Dr.
Oct. 24r 18b5.J
Henry 0. Coe, recording secretary; Dr. Emil Noeggerath, cor-
responding secretary; Dr. Edward L. Partridge, treasurer; Dr.
James B. Hunter, pathologist; Dr. Colin Mackenzie, Dr. Bache
McE. Emmet, and Dr. Clement Cleveland, members of the com-
mittee on admissions (to hold office from 1885 to 1887, acting
in conjunction with Dr. Kobert Watts, Dr. H. T. Hanks, and
Dr. J. B. Hunter, who continue in office until 1886).
Infectious Diseases in New York. — We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the three weeks ending October 20, 1885 :
2 weeks ending Oct. G.
Week ending Oct. 30.
DISEASES.
Cases.
Deaths.
Cases.
Deaths.
Typhus
2
1
3
1
78
16
33
12
40
3
21
3
Cerebro-spinal meningitis. . . .
2
2
4
4
6
1
6
0
79
33
53
22
11
0
1
1
The Health of Foreign Cities. — We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office since
the date of the last bulletin, October 7th: Montreal, Canada.
— October 1st to 13th: 391 deaths from small-pox, in the city,
and 101 deaths in adjacent municipalities. Kingston, Canada.
— October 2d : Free from epidemic diseases. Three Rivers,
Canada. — For the week ending October 10th : 6 cases and 2
deaths from small-pox. Toronto, Canada. — For the week end-
ing October 10th : 1 case of small-pox reported ; 3 cases are
now being treated in hospital. Havana, Cuba. — For the week
ending October 8th : 20 cases and 10 deaths from yellow
fever. Cardenas, Cuba, September 26th ; Matanzas, Cuba, Oc-
tober 7th; St. Thomas, October 2d; San Domingo, September
28th, and Cape Haytien, Hayti, September 26th : All free from
epidemic diseases. Acapulco, Mexico. — For the week ending
September 27th : 4 deaths from yellow fever. Guaymas, Mexi-
co.— For the month of September : 200 cases and 47 deaths from
yellow fever ; 26 of the deaths were among officers and soldiers.
Callao, Peru. — September 5th : 1 death from small-pox. Yel-
low fever has disappeared. La Guayra, Venezuela. — For the
week ending September 12th : Free from epidemic diseases.
Yellow fever is, however, prevalent and fatal at Caracas.
Buenos Ayres. — For the months of July and August : 205 deaths
from small-pox. London, England. — For the three weeks end-
ing October 3d : 15 deaths from small-pox. Glasgow, Scotland.
For the week ending October 3d : 1 death from small-pox.
Edinburgh, Scotland. — For the week ending September 12th:
1 death from small-pox. Bradford, England. — September 19th :
1 case of small-pox reported. Paris, France. — September 26th
to October 8th: 4 deaths from small-pox. Bordeaux, France.
— For the week ending October 3d: 2 deaths from small-pox.
Antwerp, Belgium. — For the week ending October 3d: 2 deaths
from small-pox. Barcelona, Spain. — From September 10th to
20th: 425 cases and 170 deaths from cholera; also 1 case of
small-pox reported. Cholera is abating and assuming a milder
form in all the districts. Cadiz, Spain. — September 19th: To-
tal mortality during the week, 186. Average mortality, 40.
The excess is attributed to cholera. September 26tb : 118 deaths
from cholera during the week. Valencia, Spain. — September
19th: 3 cases and 1 death from cholera. The port (Grao) of
Valencia is now supposed to be free from cholera. Gibraltar,
Spain. — For the week ending September 27th: 2 cases and 2
deaths from cholera. From August 1st to date of report there
465
had been 24 cases and 19 deaths from cholera. October 4th :
No new cases of cholera within the past eleven days. Tarra-
gona, Spain. — From September 1st to 28th : 75 cases and 37
deaths from cholera. No new cases reported since the 24th.
Genoa, Italy. — From September 20th to October 4th : 5 cases
and 2 deaths from small-pox. Venice, Italy. — From September
5th to 19th: 17 cases of small-pox. Trieste, Austria. — From
September 2d to 26th : 23 cases and 6 deaths from small pox.
Prague, Bohemia. — September 24th : 1 death from small-pox.
Zurich, Switzerland. — From September 12th to 30th : 2 deaths
from small-pox. Warsaw, Russia. — From September 12th to
26th: 5 cases and 4 deaths from small- pox. Calcutta, India. —
From August 2d to September 5th: 19 deaths from cholera.
Jerusalem, Palestine. — For the months of May, June, and July:
Small-pox reported prevalent. Colombo, Ceylon. — August 15th;
34 cases and 24 deaths from cholera reported.
The following is the number of cases and deaths from chol-
era in Spain, from March 4th to September 17th, inclusive :
259,684 cases and 96,094 deaths. In Italy, from August 4th to
September 13th, there were 165 cases and 89 deaths from
cholera.
The Washington Obstetrical and Gynaecological So-
ciety.— At the annual meeting, held on the 16th inst., officers
were elected for the ensuing year as follows: Dr. A. F. A.
King, president ; Dr. W. W. Johnston and Dr. J. Taber John-
son, vice-presidents; Dr. C. H. A. Kleinschmidt, recording
secetary ; Dr. S. S. Adams, corresponding secretary ; Dr. G. B.
Harrison, treasurer; Dr. C. F. Hagner, Dr. L. Tyler, and Dr.
Adams, committee on business ; Dr. G. N. Acker, Dr. H. H.
Barker, and Dr. H. D. Fry, committee on admissions ; Dr. T. 0.
Smith, Dr. J. R. Bramwell, and Dr. Kleinschmidt, committee
on publicaton ; and Dr. Acker, Dr. G. W. Johnston, and Dr.
Harrison, committee on pathological specimens.
The New York Academy of Medicine.— A special meet-
ing was held on Monday evening, the 19th inst., for the purpose
of founding a section in ophthalmology and otology. Dr. C. R.
Agnew was chosen president, and Dr. J. A. Andrews secretary.
The meetings will be held on the third Monday of each month,
excepting July, August, and September.
The late Professor Charles Robin is thus spoken of by the
Paris correspondent of the London "Medical Times and Ga-
zette": "The history of Professor Robin was for a long space
ot time the history of medical microscopy itself, and he stood
prominent as the representative of that branch of study in
opposition to Velpeau and other practical and clinical teachers,
who endeavored to cast ridicule upon the microscope and his-
tology as viewed in relation to medical science. The triumph
of Robin appeared complete when, in 1861, a chair of histology
was created at the Faculty of Medicine, of which he became, of
course, the first occupant. His success was great at first, but
he soon became unpopular with the students on account of his
extreme severity as an examiner ; while, on the other hand, the
clerical party, then predominant, were incensed at the so-called
materialistic tendencies of his lectures and writings. The com-
bination of these two hostile forces led to violent scenes, in
which the professor was hissed, abused, and prevented from
speaking. At a later period he regained his popularity through
the petty persecutions of the clerical party, which, among other
annoyances, excluded him from the list of persons qualified to
sit upon a jury, although at this time Robin was unquestionably
one of the most celebrated men of science in Europe. He had
become, in spite of strenuous opposition, a member of the In-
stitute in 1866. When the Senate was created in 1870, Robin
was named a Senator by his native department (Ain). He re-
MINOR PARAGRAPHS.
46'!
LETTERS TO THE EDITOR.
[N. Y. Mcu. Joub.,
mained a member of the Assembly till bis death, although in
politics, like many scientific and literary celebrities, he was con-
tent to play a dumb part. Indeed, both his qualities and de-
fects made him unfit to play the part of a Demosthenes ; he had
neither the eloquence nor the assurance which are the stamps
of the political orator, and which are seldom developed by a
severe process of scientific training. Robin was one of the
chief disciples of Auguste Comte, and one of the founders of
the celebrated Societe de liologie, along with his intimate friend,
Claude Bernard. He was also closely connected with Littre,
and became with him one of the joint editors of the Dictionnaire
de Nysten, which, although in the beginning a mere vocabulary
of words employed in medical science, became a stumbling-block
to orthodox believers and a sort of gospel to the followers of
positivism, through the extreme boldness of some of its defini-
tions, those, for instance, of Ame, Homme, and a few others of
the same description. In private life Robin was a most amiable
and disinterested man. All his pupils were much attached
to him, and he will be sincerely regretted by his numerous
friends."
Obituary Notes.— The death of Dr. William Workman, of
Worcester, Mass., took place on Saturday, October 17th, in the
eighty-seventh year of his age. He was born in Colerain, Mass.,
was graduated from Harvard Medical School in 1825, and be-
came a member of the Massachusetts Medical Society in 1831.
After practicing in Shrewsbury, Mass., for ten years, in 1835,
he settled in Worcester, where he has since resided. He was
for ten years a trustee of the Worcester State Lunatic Hospital.
Army Intelligence— Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department
United States Army, from Octoier 11 to October 17, 1885:
Irwin, B. J. D., Lieutenant-Colonel and Assistant Medical Pur-
veyor. Ordered from Department of Arizona to New York
city for temporary duty in charge of Medical Purveying
Depot at that place, relieving Captain Henry Johnson,
Medical Storekeeper. S. O. 233, A. G. O., October 10, 1885.
Moreis, Edward R., First Lieutenant and Assistant Surgeon
(recently appointed). Ordered for duty in Department of
the Missouri. S. O. 233, A. G. 0., October 10, 1885.
Naval Intelligence.— Official List of Changes in the Medi-
cal Corps of the United States Navy for the week ending Octoier
17, 1885.
Baldwin, L. B., Passed Assistant Surgeon. Detached from
Naval Hospital, Philadelphia, and ordered to Navy-YTard,
Mare Island.
Dickinson, D., Surgeon. Detached from Naval Hospital, Mare
Island, and ordered to Training Ship Portsmouth as relief to
Surgeon A. M. Moore.
Moore, A. M., Surgeon. Detached from Training Ship Ports-
mouth, and to await orders.
Shafer, Joseph, Assistant Surgeon. Detached from Receiving
Ship St. Louis, and ordered to Naval Hospital, Philadelphia,
as relief of Passed Assistant Surgeon Baldwin.
Hester, F. A., Assistant Surgeon. Detached from U. S. S.
Minnesota, and ordered to the Tennessee as relief of Passed
Assistant Surgeon Nelson II. Drake.
Drake, Nelson H., Passed Assistant Surgeon. Detached from
the Tennessee 31st inst., and to await orders.
Marine-Hospital Service. — Official List of Changes of
Stations and Duties of Medical Officers of the United States
Marine- Hospital Service, for the week ended Octoier 10, 1885.
Bailiiache, P. II., Surgeon. To proceed to Tuckerton, N. J.,
as inspector. October 7, 1885.
Austin, H. W., Surgeon. To proceed to Albany, N. Y., on
special duty. October 6, 1885.
Gassaway, J. M., Surgeon. To examine surfmen at Eilsworth,
Me., and other ports of First District Life-Saving Service.
October 9, 1885.
Society Meetings for the Coming Week :
Monday, Octoier 26th : Medical. Society of the County of New
York; Boston Society for Medical Improvement; Lawrence,
Mass., Medical Club (private) ; Cambridge, Mass., Society
for Medical Improvement.
Tuesday, Octoier 27th: New YTork Dermatological Society;
New York Surgical Society ; Buffalo Obstetrical Society
(private) ; Medical Societies of the Counties of Putnam (quar-
terly), Queens (semi-annual — Garden City), and Rockland
(semi-annual), N. Y. ; Boston Society of Medical Sciences.
Wednesday, Octoier 28th : New York Pathological Society ;
American Microscopical Society of the City of New York ;
Philadelphia County Medical Society (conversational) ; Au-
burn, N. Y., City Medical Association ; Berkshire, Mass.,
District Medical Society (Pittsfield); Medical Society of
Gloucester County, N. J. (quarterly) ; Middlesex, Mass.,
North District Medical Society (Lowell) ; American Academy
of Medicine (New Y'ork — first day).
Thursday, Octoier 29th: New York Orthopaedic Society (at
214 East Thirty-fourth Street. Two or three short papers
on "Rotary Lateral Curvature"); Cumberland County, Me.,
Medical Society (Portland); Massachusetts Medical Benevo-
lent Society (annual) ; American Academy of Medicine
(second day).
f tilers iff % Obiter.
LACERATIONS OF THE CERVIX UTERI.
Jersey City, N. J.
To the Editor of the New York Medical Journal:
Sir : In your report of the proceedings of the Medical Soci-
ety of Virginia, on the 10th inst., I noticed an abstract of a pa-
per read by Dr. Bedford Brown, of Alexandria, on the "Treat-
ment of Lacerations of the Os and Cervix Uteri without Surgi-
cal Operation." I read the same with great interest, and fully
indorse the treatment he suggests. It has been followed by me
for many years with excellent results. The graduated solutions
of nitrate of silver, 3j to 3ij, and 3 j to 1 oz. of water, enable
the physician to select the required strength adapted to the par-
ticular case. I have always used cotton on the end of an appli-
cator, in preference to a camel's-hair brush, as it can be thrown
away and a new piece used for each application ; or, when there
is enlargement of the cervix, I moisten or saturate the same
with glycerin, which has the property of causing a serous dis-
charge, and thereby tends to reduce the size of the cervix.
When the cervix is large and indurated, I know of nothing
equal to hot-water injections, once or twice a day, and con-
tinued until the desired results are obtained — softening and a
return to the normal size. For this purpose I prefer the fount-
ain syringe to any other I know of. I have lately finished the
treatment of two patients who had suffered from lacerations of
the os and cervix uteri. They were treated principally with
the nitrate-of-silver solutions, Lugol's solution, hot-water injec-
tions, and occasionally scarifications of the cervix. Both en-
tirely recovered. James Craig, M. D.
Oct. 24, 1885.]
PROCEEDINGS OF SOCIETIES.
467
RIVAL PREPARATIONS OF COCA.
133 East Thirty-eighth Street, N. Y., October 14, 1885.
To the Editor of the New York Medical Journal :
Sir: In your issue of January 3, 1885, page 19, in a report
of a paper read before the New York Medical Society, on
"The Physiological and Therapeutical Effects of the Coca-Leaf
and its Alkaloids," occurs the following: "For the past ten
years Dr. Fauvel has used it, both internally in the form of Vin
Mariani, and also by local applications to the pharynx and
larynx in spray or by brush, in the form of a fluid extract, or,
more recently, of a concentrated non-alcoholic preparation
more of the nature of a cordial (prepared by Mariani & Co.)."
Several manufacturers of coca preparations have taken occa-
sion to quote from this paper, each in turn substituting the
name of his own production instead of the one mentioned in the
original.
As the preparations of coca mentioned in my paper were
personally tested and found to be the best of a large number
experimented with, I wish to call attention to these misquo-
tations and substitutions.
Very truly, W. Oliver Moore.
*„.* We have taken the trouble to compare the report of Dr.
Moore's remarks with the little book on coca prepared by M.
Mariani, and the latter with the circulars issued by a number of
manufacturers of coca preparations; and we certainly think
that some of these manufacturers have taken an unwarrantable
liberty in appropriating work that evidently cost M. Mariaui a
good deal of time and no little outlay of money.
flroceebntcjs of Societies.
NEW YORK PATHOLOGICAL SOCIETY.
Meeting of October 14, 1885.
Dr. George F. Shrady, President pro tern.
Melano-Sarcoma of the Face. — Dr. John A. Wteth pre-
sented a woman seventy years of age who showed the results of
an operation for removal of a melano-sarcoma of the face. Four-
teen years ago a small tumor appeared at the left of the nose,
and remained nearly stationary for several years, after which it
enlarged gradually. The integument alone seemed to be impli-
cated. Four years ago it was burned with some escharotic. A
short time ago Dr. Fox made a diagnosis of melano-sarcoma,
and sent the patient to Dr. Wyeth for operation. Dr. Wyeth
carried the incision from well up on the nose outward an inch
and a half, and a quarter of an inch below the palpebral border.
The gap was filled with integument drawn over the malar bone.
The operation was done only two weeks ago, but perfect union
existed at present and there was no ectropion.
A Cast of the Bladder. — Dr. H. J. Boldt presented a cast
of the bladder of a woman aged eighteen years who had recent-
ly given birth to her first child. Delivery was normal. Soon
afterward, September 21st, she complained of pain in the hypo-
gastric and lumbar regions. There was tenderness on pressure.
Micturition caused no pain. The urine contained albumin,
blood-casts, and a small quantity of pus. The diagnosis was
made of catarrhal nephritis. At this time the temperature wai
102-6° F., but some days later it rose to 106°. The patient
felt something in the urethra while urinating, and, on examina-
tion, Dr. Boldt thought the sac to be a portion of the inverted
bladder. He replaced it, and did so several times subsequently.
Dr. Lusk, who saw the patient in consultation, thought it to be
an inversion of the bladder, and, as the presenting portion was
becoming putrid, it was dusted with iodoform. Finally it was
expelled and was found to be, as Dr. Boldt believed, the mucous
membrane of the bladder with some submucous tissue and per-
haps some of the muscular fibers. He had not examined it mi-
croscopically, and consequently wished that it be referred to the
Microscopical Committee. After its expulsion, the bladder-walls
seemed to be entirely denuded of their lining membrane, and
became thickened, and the cavity greatly decreased in size. A
large quantity of urine was passed during the twenty-four hours.
The patient died, on the 10th of October, with cerebral symp-
toms, probably of a septic nature.
Large Sarcoma of the Ovary. — Dr. CusniER presented a
sarcomatous tumor, probably of the ovary, as large as a bucket,
removed post mortem. The patient, forty-nine years of age,
otherwise healthy, had first noticed an enlargement of the ab-
domen about a year previously ; the increase in size was then
very rapid. Her health had become greatly impaired when she
was seen by Dr. Cushier. Dr. Hunter saw her in consultation,
and an exploratory incision was made, but the operation was
discontinued. The patient died on the fifth day afterward,
probably of disappointment at not having the tumor removed^
and of exhaustion. There was found to be slight red hepatiza-
tion of the left lung, with some pulmonary nodules of the nature
of the abdominal tumor, and nodules in the retro-peritoneal
glands. The tumor involved the left ovary and the uterus, and
was pronounced to be a spindle-and-round-celled sarcoma, prob-
ably originating in the ovary, the more common origin of such
growths.
Dermoid Cyst of the Ovary.— Dr. Cosiiier also presented a
dermoid cyst of the ovary removed last Thursday. It had been
of comparatively rapid growth. There was gome elevation of
the temperature prior to the operation. Adhesions existed
throughout, but were not firm. The larger cavity was filled
principally with sebaceous material ; only a small pouch was
occupied by hair.
Congenital Cyanosis. — Dr. L. E. Holt presented the heart,
lungs, and kidneys of a child which had died of congenital cya-
nosis, forty-eight hours after birth. There was a distinct syphi-
litic history ; the child was born about the eighth month; it
weighed between four pounds and four pounds and a half, and
was cyanotic. The respiration was very rapid, and the pulse
could not be counted. Examination of the lungs showed over
both sides marked diminution in resonance and many fine rales.
At the autopsy the lungs were found to be solid, did not crepi-
tate at all, and sunk in water; it was difficult to find with the
unaided eye any air cells which had been distended. The fora-
men ovale was sufficiently large to admit two fingers; the right
ventricle was slightly thickened ; there was no disease of the
valves. The spleen was enlarged and bard, and showed venous
congestion. Externally the kidneys were slightly softened ; the
cortex was quite pale, and the pyramids were somewhat con-
gested, showing uric-acid infarctions. There was interstitial
nephritis.
PHILADELPHIA PATHOLOGICAL SOCIETY.
Meeting of September 24, 1885.
The President, Dr. E. 0. Shakespeare, in the Chair.
Taenia Echinococcus. — Dr. William Osler presented speci-
mens of this rare parasite, which had been reared experimental-
ly by feeding a dog with hydatids from the liver of a pig. The
animal was killed about seven weeks after the feeding, and the
small intestine was found to contaiu many hundreds of the ma-
408
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jouk.,
tare tape-worms. The portion of bowel exhibited had many
adherent to the mucous membrane. From the small size of the
worms, only a few lines in length, they were very apt to be
overlooked. Cobbold stated that the only specimens procured
in England had been experimentally reared. Dr. Leidy had
never met vvitli the adult worm in this country. That it must
occur here in the dog was very evident from the frequency with
which echinococcus cysts (the larvae) were met with in the hog
and other animals.
Cysticercus Cellulosse. — Dr. Osleb exhibited the heart, the
brain, and a portion of the flesh of a pig, containing the " mea-
sles," as the larva3 of the Tmnia solium were called. Both
organs were thickly studded with the cysts, which were also
very numerous throughout the muscular system. The animal
was fat and had seemed to suffer very little inconvenience. At-
tention was called to the cysts beneath the tongue and to the
possibility of telling whether an animal was measled by an ex-
amination of this part during life. Microscopic slides of the
parasites were shown and a slide of a cysticercus, with a very
large caudal vesicle, from the omentum, in which situation it
might grow to the size of a walnut.
Distoma Hepaticum ; its Effects on the Liver. — Dr. Osler
also showed the liver of an ox, showing enormous enlargement
of the bile-vessels and calcification of their walls, due to the
chronic inflammation excited by the presence of the flukes. The
main ducts were thicker than the thumb, and even the smaller
tubes were as hard as the stem of a clay pipe. The liver sub-
stance was wasted but not cirrhotic. In spite of this extensive
disease, the animal was well nourished. Specimens of the flukes
in spirit and mounted were also shown.
Taenia Flavopunctata. — Dr. William Pepper presented
the specimens of Tmnia flavopunctata described by Prof. Leidy
in the " American Journal of the Medical Sciences V for July,
1884. This species had never but once before been seen and
recognized, and then by Weinland, of Boston, in 1858. Both
specimens had been expelled from young children and averaged
twelve inches in length.
Taenia Mediocanellata.— Dr. Pepper also presented the
head and neck of a Tmnia mediocanellata. It had occurred in
a young man. A course of starving, followed by castor-oil and
pelletierine, had removed a portion of the worm ; afterward a
repetition of the starving process, without the castor-oil but
with the alkaloid, had brought away the entire worm dead.
Dr. Pepper said he was particularly interested in this series; it
spoke forcibly of the necessity of studying comparative patholo-
gy. The specimens were very perfect and more instructive
than more highly organized species. In practice he had found
the Tmnia mediocanellata as difficult to expel as the Taenia
solium. The exhibition of the small variety, the Tmnia flavo-
punctata, taught the necessity of careful examination of the
stools.
Litholapaxy. — Dr. de Schweinitz exhibited the kidneys,
ureters, and bladder of a man who had died after this opera-
tion. The patient, aged seventy-three years, had for two years
previous to the operation suffered with straining during the act
of micturition and other symptoms of hypertrophy of the pros-
tate gland, and of vesical calculus. The urine contained albu-
min, pus, epithelium, and granular casts, and had a specific
gravity of 1 -01 8. The patient's habits were intemperate. The
operation of Litholapaxy was performed, marked difficulty hav-
ing been experienced in the introduction of the instruments.
After the operation the patient exhibited great restlessness, praa-
cordial pain, and a rapid, feeble pulse. Subsequently he became
comatose, and died twenty hours after the operation, the im-
mediate cause of death being, apparently, the formation of a
heart-clot. A post-mortem examination was made about ten
hours after death. Old pleuritic adhesions were found on the
right side. The muscular structure of the heart was flabby ;
there was a firm " chicken-fat " clot in the right ventricle. The
liver was slightly enlarged and soft. Both kidneys were granular
and contained oysts. The bladder was thickened, and showed
ecchymoses on its mucous surface. The prostate was enlarged.
Dr. Tyson thought this case added one more to the list
showing the impropriety of crushing for stone when kidney
disease was present. He did not know why, but under such
circumstances the cutting operation was more suitable. He cited
the case of Louis Napoleon as an instance of the danger of
crushing in the presence of kidney disease. In answer to a
question of Dr. Barton's regarding the kidneys, he said that they
were contracted, though not decidedly so, as there was good
secreting structure left. The cysts were part of the pathologi-
cal anatomy of granular kidney. He believed the cause of
death to have been uraemia.
Dr. G. G. Davis said that in such cases a post-mortem ex-
amination was in reality of the nature of an investigation.
Death might be due to direct violence done the urethra, the
prostate, or the bladder; or it might be due to extension of in-
flammation to the peritonaaum, or to some unknown cause, as
in the present case.
Dr. de Schweinitz said that the urethra was not examined,
and agreed with Dr. Tyson that the cause of death was uraemia.
This was the more probable because an officious attendant,
against orders, had administered rather full doses of morphine.
Syphilitic Abscess and Necrosis of the Tibia.— Dr. Henry
Beates presented a specimen of syphilitic abscess and necrosis
of the tibia removed by amputation at the middle of the thigh.
The patient was a strumous man who three years previously
had suffered from an attack of obstinate sciatica accompanied
by a marked degree of muscular atrophy of the affected limb,
followed by lameness. Two years later a swelling developed at
the femoral side of the gluteo-femoral crease, which opened and
discharged small fragments of necrosed bone. The sinus was
finally healed and fair health enjoyed for several months. Sev-
enteen weeks ago osteitis of the tibial head developed, followed,
in a short time, by suppurative synovitis. The pus perforated
the ligamentum posticum and burrowed beneath the gastrocne-
mius, elevating it and the posterior tibial muscular structures
from the bone. Free incision evacuated this, but the destruc-
tive process continued, resulting in the formation of sinuses and
complete disintegration of the joint. Hectic was pronounced,
and. to save life, amputation was performed on the day previous.
Longitudinal section through the femur, joint, and tibia disclosed
the extensive destruction effected in so comparatively short a
time. The articulating surface of the condyles was denuded of its
cartilage and the surtace of the bone was roughened. The pa-
tella was bound firmly to the trochlear portion of the condyles.
The articular elements were destroyed. The head of the tibia was
completely necrosed and broken down. The medullary canal
of the tibia, throughout its entire extent, was infiltrated with
pus. The surface of the bones was also the seat of the morbid
process. The pus from the joint had burrowed upward beneath
the internal and external vasti muscles and deprived the femur
of its periosteum for a considerable distance. The anterior faoe
of the tibia was denuded in like manner, while the crest, at the
middle, was the seat of ulceration. At the time the disease oc-
curred the patient first noticed a chancre. Six weeks later the
secondary phenomena developed and were promptly met with
anti-syphilitic remedies. Was the strumous disease influenced
by the syphilis ? The specimen was referred to the Committee
on Morbid Growths for microscopical examination, with instruc-
tions to look for tubercle bacilli and for those said to be peculiar
to syphilis.
Oct. 24, 1885.1
PROCEEDINGS OF SOCIETIES.
469
DrT Davis was desirous of knowing if the disease of the head
of the tibia was due to scrofula or syphilis ; the worm-eaten
character of the ulcer on the tibia looked like syphilis.
Dr. C. M. Wilson inquired if there had been fever, rigors,
and evidences of pyaemia in this case. It was undoubtedly one
of osteo myelitis, and in a similar case of traumatic origin, which
he had exhibited, rigors had been present.
Dr. Jurist asked how the presence of acute syphilis in the
patient would affect the prognosis of the operation.
Dr. Beates replied that there had been symptoms of septic
fever, and, as the acute symptoms of syphilis had been absent
for some weeks, he did not think this would affect the prog-
nosis.
Sudden Death from Laryngeal Obstruction.— Dr. Louis
Jurist presented the larynx and trachea removed post mortem
from the body of man, aged thirty -eight, a book-keeper, who
had suddenly died. He had not had syphilis. He had taken
cold on Saturday and had a sore throat; on Tuesday he chatted
with the doctor, and an examination gave no evidence of any-
thing except ordinary pharyngitis ; on Wednesday he went to
his business ; on the evening of this day the doctor was sent for
in haste, and, on going at once, found the man dead. Never-
theless, a hurried laryngotomy was done, and efforts were made
to restore the heart, but without avail. Dr. Jurist removed the
larynx through the thoracic cavity. He was in doubt as to the
mode of death. The lungs were fairly healthy, though cheesy
on one side. There must have been an abscess present.
Dr. Tyson was surprised that marked improvement should
have followed the treatment by emetics and sedatives, as the
abscess must have been present; perhaps the outlying oedema
was subdued and the condition thus improved.
Dr. Wharton had had no experience in such cases, but agreed
with Dr. Jurist that the operation of tracheotomy, and not
laryngotomy, was indicated.
Dr. Jurist was in doubt in regard to the diagnosis; it rested
between perichondritis and a subsequent abscess or phlegmonous
laryngitis. He was inclined to the former view.
BROOKLYN PATHOLOGICAL SOCIETY.
Meeting of May 14, 1885.
The President, Dr. B. F. Westbrook, in the Chair;
Dr. A. H. P. Leuf, Secretary.
Pulmonary Abscess and Pyaemia.— Dr. Glentworth R.
Butler read an account of a case, for Dr. Lewis S. Pilcher.
[It was reserved for publication.]
. A Cranio-rhachitic Monster with Exomphalos was shown
by Dr. W. J. Brandt.
Valvular Aneurysm. — A paper with this title was read by
Dr. Albert Brinkman. [See page 455.]
Pulmonary Miliary Tuberculosis.— A fresh specimen was
shown by Dr. A. H. P. Leuf.
Meeting of June 11, 1885.
Intra-capsular Fracture of the Femoral Neck.— Dr. J. H.
Hunt presented a specimen of this kind, in which there had
been an impaction of the neck into, and the formation of a false
joint within, the great trochanter.
The President considered it a remarkable case because of
the site of the false joint.
Dr. Z. T. Emery presented a specimen of the same injury,
with a false joint.
Dr. Hunt remarked that it was peculiar in that there were
fibrous connections, like so many chordae tendineae, between
the false-joint surfaces in place of a ligamentum teres. He
asked if it was possible for a heavy woman, as this one was, to
have her hip give way spontaneously instead of its being due to
violence.
The President could not account for the impaction except
by violence. He questioned whether a spontaneous fracture
could have caused the fall of the woman, and this, in turn, have
given rise to the impaction.
Dr. Hunt rejoined that she was very intelligent and dis-
claimed having stumbled. There was no history of tripping.
The fall seemed to be spontaneous. He simply desired to know
whether it was possible that the fracture could have preceded
and caused the fall and the latter the impaction. He hardly
supposed it probable, but did not consider it impossible.
Acute LeptO-meningitis.— Dr. Arnold Stub read the his-
tory of a case as follows :
a A gentleman, thirty-seven years of age, of steady habits,
whose former history gave no clew to any previous disease, and
who for years past had no other complaint except an occasional
severe neuralgic pain in the face, for which it seems, however,
he never consulted a physician, returned from a theatre during
a cold and stormy night (March 28th) at 11.30. It seems he
went to bed perfectly well, but awoke at 2 a. m. (March 29th)
and called the members of his family to his room, on account of
a severe attack of vomiting he had been seized with. It seems
he offered no explanation as to how he felt, but lay in bed con-
stantly vomiting and moaning, and, upon being asked what
ailed him, only said: 'It is awful.' It seems that his family
thought he had been eating or drinking something unusual, and
waited until morning before they sent for me. Upon my arri-
val, about 9 a. m., March 29th, I found him lying in bed, continu-
ally tossing about, smiling and grinning in a peculiar, almost idi-
otic manner, and talking at random. Upon being asked how he
felt, he declared he felt all right, and had no pains, but he point-
ed toward his abdomen if the question was pressed. He still
vomited occasionally. The pulse was 80 and, like the tempera-
ture, the heart's action, and the pupils, perfectly normal. Upon
inquiry, I could not learn when he had urinated last. He cer-
tainly had not done so since 2 a. m. Percussion showed the
bladder to be empty. The introduction of a catheter was im-
possible on account of his restlessness. I diagnosticated uraemia.
Taking into consideration the entire absence of all symptoms
tending toward brain trouble, his apparently empty bladder, the
fact that he had been sitting in a hot, closely packed theatre,
and afterward returned home during a snow-storm, I felt justi-
fied in coming to such a conclusion, and I ordered fifteen grains
of calomel to be given at once, and, two hours afterward, one
ounce of castor-oil, which he took and retained. I also ordered
liq. ammonii acetatis, 3 ij, every hour, and hot bran-bags to be
applied to the lumbar region. About noon of the same day I
found no effect from the calomel and castor-oil. An enema
passed his bowels without producing a faacal evacuation, and
there was no change in the symptoms or improvement of the
patient. I then called Dr. Wallace in consultation, who, upon
examining the patient, coincided with my views and suggested
that twTo drops of croton-oil be given. It was done and repeated
in two hours, but without effect until late in the evening, when
an enema, consisting of castor- oil, soap, salt, and warm water,
produced one copious stool. No urine having passed, I man-
-aged to introduce a catheter, and, to my surprise, I succeeded
in withdrawing one quart of urine, which proved to have a spe-
cific gravity of 1*024, and to contain no albumin, no casts, no
blood-coloring matter, but to contain a normal quantity of urea,
no sugar being present. No change of symptoms hud taken
place since morning, so I concluded to continue the treatment,
and prescribed only thirty grains of bromide of potassium at
bedtime. Early in the morning of March 30th Dr. Wallace and
I met again and concluded to call in Dr. Gray for consultation.
470
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
The latter, after examining the patient, came to the conclusion
that, provided we were able to exclude kidney disease, menin-
geal trouble, with a strong suspicion of syphilitic origin, would
have to be considered next, and therefore he recommended the
use of iodide of potassium, gr. viij, three times daily, bromide
of potassium, 3 ss., three times a day, and hyoscyamine, gr.
every four hours. From the time I introduced the catheter the
day previous the patient did not urinate. I catheterized again
at 4.15 p. m., March 30th, and withdrew a pint and a half of
urine, which corresponded exactly with the urine of the day
previous. The patient had been fed March 29th and 30th with
gruel and beef-juice and water whenever he showed any incli-
nation to take them. Thirst did not seem to trouble him. His
general condition remained the same as upon the day previous;
he would answer questions in a rather incoherent way. Upon
being asked to get up and walk, he would do so without any
apparent effort. At 6.15 of the same evening he was taken
with a cough and expectorated a good deal of mucus. At 6.35
he became very restless, and his pulse ran up to 112. Five min-
utes later he had a convulsion. I administered at once some
chloroform by inhalation, but without effect upon the convul-
sions. I telephoned at once to Dr. Wallace and Dr. Gray. The
former was not at home. The latter responded to my call and
recommended the use of amyl nitrite by inhalation, and, no
effect being produced upon the convulsions, a hypodermic injec-
tion of thirty drops of tincture of veratrum viride. As already
mentioned, the pulse was 112 five minutes before he had the con-
vulsions ; at 7.15 it was 140 ; at 7.25, 180, with a respiration of 28
a minute. The pulse varied between 180 and 160, with a respira-
tion of 40, until 8.55, when I administered thirty drops of tincture
of veratrum viride hypodermieally. Three minutes afterward
the pulse fell to 144. Five minutes later it was 140, and then
it gradually fell until it came to 96, at 9.35, and remained so
until the patient died, in convulsions, at 10.30 of the same even-
ing. The following day Dr. Leuf performed the autopsy, and
will relate to you the details of the same."
Report of the Autopsy, hy Dr. Leuf. — "'The patient was a
strong, well-built male. The autopsy was held about twenty
hours after death, and rigor mortis was well marked. Both
kidneys was found in a state of the most intense congestion it
was possible to see. The blood almost welled out of them as
soon as the tension of their substance was relieved by section.
Pressure caused additional free sanguineous exudation. They
had a very deep purple color and were both alike. The bladder
was empty. The other abdominal and the thoracic viscera pre-
sented nothing unusual in appearance as to congestion or other
anomalous conditions. The pia mater was intensely injected
and perfectly dry on the surface, while beneath it, upon the
cerebral surface, there was a large amount of widely diffused
extravasated blood. The haemorrhage most likely originated in
the smaller vessels of the pia at the bottom of the sulci, because
when no blood appeared upon the surface it was found in abun-
dance at the bottom of the fissures, and none was found on the
surface of a convolution without its being discovered in the
adjacent furrows in sufficient amount to distinctly separate the
contiguous walls. In my opinion the meningeal inflammation
was caused by the kidney congestion, but, as there is room for
honest difference of opinion on this point, I prefer to leave its
consideration to others."
Dr. William Wallace had been puzzled with the case. He
had thought that there was no brain trouble, and had considered
it renal. The condition of the brain surprised him. He con-
sidered the kidney trouble primary. He had never seen bloodi-
er kidneys. He thought that Dr. Leuf's theory might be cor-
rect, but acknowledged that the results of the autopsy made
him more puzzled than ever.
Dr. Stub was able to quote but one authority in favor of
renal disease producing meningeal affections. A man in ''von
Ziemssen," in a long letter, held that kidney disease often pro-
duced meningeal trouble. Dr. S. G. Armor, he then recollected,
had also made a similar statement at the Kings County Society.
Acute hyperaemia resulting from nephritis might end in sudden
death, but in this case it was more than a hyperajmia.
The President asked if Dr. Stub still considered the case
one of uraemia.
Dr. Stub replied that he did not, and that he had made out
the death certificate for lepto-meningitis.
Dr. Albert Bkinkman remarked that Loomis said that renal
disease often caused serous inflammations, and especially if an
acute attack occurred during the chronic disease.
The President thought that the intense vomiting, without
any other symptom, excluded uraamia. Inasmuch as much fluid
would be evacuated by continuous emesis, it could not be ex-
pected that a normal amount of urine would be passed. The
paralysis of the bladder was indicative of cerebral or spinal
trouble. He thought the renal congestion accidental. We often
found many internal congestions in case of sudden death. He
thought there was hardly enough uraemia to account for the
meningeal trouble. He would ask if there had been any other
symptom besides vesical paralysis to indicate disease of the cord.
Dr. Stub answered, No." In reply to the question, whether :
there had been anything noticed in the vomited material to in-
dicate poisoning, Dr. Stub said that there had not.
Dr. Leuf explained that he believed the kidney trouble to
have caused the meningeal inflammation for several reasons.
The meningitis was in the first, or dry, or congestive stage, a
condition rarely met with of so marked a type. The kidney
congestion must have been of several days' duration, as the ex-
tensive and universal corpuscular infiltrations of the kidney sub-
stance demonstrated as seen by the microscope. Penal disease
was not infrequently the cause of not only cardiac, but also
cerebral and meningeal disorders; and, while it was easy to ex-
plain this on the supposition that the increase of arterial ten-
sion all over the body, resulting from renal affections, caused
secondary congestions and inflammations in remoter organs, the
vascular apparatus of which was weakest, the reverse could not
be rationally inferred. It had just appeared that only three
authoritative statements could be adduced to uphold the views- i
he had just expressed. There certainly were many more, and *
he knew of none just now that upheld the contrary view, ihat
meningitis was ever the cause of nephritis. It also seemed to
him that the urine that had been drawn off by catheterization
had been in the bladder for some time. The catheter was not
passed at first, because percussion over the hypogastrium elicited
a tympanitic sound, but then a partly filled bladder did not pro-
ject up into the abdomen and was usually covered by coils of
the ileum distended more or less with gas. The president had
thought fit to assume a very recent origin of the nephritis, be- I
cause of the lack of ursemic symptoms, and accounted for the
small amount of urine voided by the copious discharge of liquid
in continuous emesis. Now, it seemed just as plausible to sup-
pose that in spite of urinary retention, due to intense nephritis,
sufficient urea was passed by the mouth in the vomited matter
to prevent uraemic symptoms. Concerning the chair's allusion
to the congestions so common in cases of sudden death, he
would only say that, having made a very large number of au- .
topsies in just such a class of cases, he had not only never seen
anything like such a congestion in such cases, but even not in
any kind of case whatever.
Dr. Stub asked if the coagulability of the blood was not a
sign of ante-mortem extravasation, and its non-coagulability of
' post-mortem effusion.
Oct. 24, 1885.]
PROCEEDINGS
OF SOCIETIES.
471
The President replied that it was not a safe rule to follow,
as some poisons might prevent coagulation.
Dr. Stub wished to know of what kind of poisoning the case
under discussion could have been.
Dr. Sewuny suggested poisoning with arsenic.
Dr. Stub rejoined that that could not be, because there was
no gastro-intestinal disturbance visible at the autopsy, no purg-
ing during life, and no reason to suspect it in any way.
Dr. Eooles asked if it might not have been poisoning with
iodide of potassium.
Dr. Stub thought it might more likely have been with chlo-
rate of potassium.
Dr. W. H. Faerington wished to know if there had been
any evidence of blood in the urine drawn during the patient's
illness.
Dr. Stub replied that there had not.
Dr. Leuf alluded to a case of poisoning with chlorate of
potassium, in which he had made an autopsy for the coroner.
It was that of a girl about fifteen years of age, and her mother
had given her by mistake about eight drachms of this drug in
as many hours. The kidneys in that case were almost exactly
like those he had described this evening, except that the Mal-
pighian corpuscles appeared as black punctate bodies, and so did
all the solitary follicles of the intestines.
Dr. Sullivan was not satisfied with the diagnosis. He
thought the conditions of the kidneys and brain were caused by
the convulsions. He had had a similar case some time before —
that of a man who came home, ate his dinner, became uncon-
scious (apparently apoplectic), regained consciousness later in
the evening, rambled in his conversation, was almost well next
morning, and wholly so in a few days. This man did not know
whether he had had convulsions or not, although such was
stated to have been the case. He was a chronic dyspeptic.
The whole trouble was probably due to some disturbing article
of food. The speaker believed the case under discussion to have
been similar to his, and death to have been due to exhaustion
of the nervous system. Sudden cold might have caused the
attack. He was still not satisfied as to the cause of death and
would like to be enlightened.
Dr. Stub replied that the last speaker's remarks would have
been more to the point if the case under discussion had begun
with convulsions. He would like Dr. Leuf to answer the ques-
tion as to the cause of death, because he ought to know it best.
Dr. Leuf informed Dr. Sullivan that it was acute lepto-
meningitis.
The President did not believe that the arterial tension
caused by renal congestion could be sufficient to cause a menin-
geal hemorrhage.
Dr. Faerington recalled a statement of Dr. Stub's about
Dr. Gray's having suspected syphilis, and desired to know if any
evidence of it had appeared.
Dr. Stub replied that there had not, and that Dr. Gray was
himself satisfied of it.
Malignant Tumor of the Sacrum.— Dr. Leuf presented
the specimen with the following abstract from the notes of the
last attending physician: On October 11, 1883, the diagnosis
was compression of the spinal cord, but was only inferential.
Eight days later, upon consultation with Dr. John C. Shaw, a
small tumor of the sacrum was noticed to the right of the me-
dian line. On January 10, 1884, the diagnosis was changed to
sacral caries, but with a doubt as to its correctness. From May
9, 1884, the diagnosis of sacral tumor was positively adhered to
until the day of death, January 6, 1885. Neither lower limb
was wholly paralyzed. Slight motion was always possible.
There was marked oedema below the knees, and later all below
the hips was very much swollen. Acetate of potassium was
given to relieve the dropsy. A large bed-sore formed at the
site of the tumor and in the vicinity. There were always
marked pain and insomnia unless morphine injections were
given. Fainting spells were frequent. The temperature ranged
from 101° to 102° F., and some tenths of a degree above;
the pulse from 96 to 120 a minute. Occasionally there were
haemorrhages from the ulcerated tumor. Microscopical examin-
ation of some of the tumor obtained with a hypodermic syringe
caused a diagnosis of encephaloid sarcoma to be made, based
upon the presence of a profusion of round cells with very little
stroma. The mode of death was by syncope. From puberty
the patient had always been a poor eater. He never liked good
substantial food, such as meat and vegetables, but only pies,
cakes, and sweets. He had always been below par in appear-
ance, looking thin, pale, and delicate. Several years before the
beginning of the disease he had a fall upon the sacrum, causing
severe local pains for several days, but from this he apparently
fully recovered.
The speaker had been requested to make the post-mortem
examination, and the following was an outline of what was
found. All the thoracic abdominal viscera presented the usual
appearances noticed in those who died of inanition. They were
all pale and atrophied, and the intestines contracted to their
utmost. A tumor was found projecting forward and upward
from the anterior surface of the sacrum so as to fully half fil^
the pelvic cavity. Upon pressure it yielded a slightly crepitant
sensation like the yielding of a very fine and incomplete cal-
careous shell, a sensation quite common in 'osteo-sarcomatous
growths, on account of the distension and thinning of the bone
by the contained growth. There was no discoloration of the
coverings of the intra-pelvic portion of the tumor. Posteriorly,
there was a gangrenous opening about 2 ctm. in diameter on a
line crossing the two posterior-superior iliac spines, and a little
to the right of the mesial plane. It was located on the summit
of a lump projecting about 4 ctm. The skin of the whole pos-
terior pelvic region was destroyed and the bone laid bare by a
deep and extensive bed-sore, involving to some extent the ex-
posed bones. The odor was very characteristic of malignant
tumor. The growth had extended laterally so as to involve
the auricular surfaces of both ossa innominata, and the muscles
in contact with them in the immediate vicinity of the sacro-
sciatic foramina. The pyriformes were wholly changed to the
appearance of the growth itself, except that they were a little
softer. The outlines of the muscles involved were also so
blended that they could hardly be discerned. The sacrum, the
lower two lumbar vertebrae, the coccyx, and the posterior thirds
of the innominata were removed, and, on section being made
through the growth, it appeared in spherical sections united by
a connective tissue, gelatinous and fluid substance.
Both lower limbs were enormously distended with oedema,
from the center of the thigh down. They appeared much as if
affected with elephantiasis. Otherwise the body was as ex-
tremely emaciated as it could possibly be. Additional bed-
sores were found along the spines of the scapula?, extending at
least 2 ctm. above and below, and exposing the aponeurosis and
substance of the trapezius and deltoid. There were some even
on the back of the elbows. Every spinous process, from that
of the vertebra prominens to the large sore at the site of the
tumor, had button- holed its way through the skin, forming a
series of irregular circular openings all along the spinal column.
Dr. Eccles said the patient had been in his hands for four
months. Two consultations had been held with Dr. Shaw, and
for some weeks Dr. Benjamin Westbrook had attended with him.
When he was first called the patient complained of intense pain
in the lumbar region combined with sciatica. The character of
the lumbar pain suggested a rheumatic complication. Treat-
472
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Joue.
ment with large doses of salicylate of cinchonidine speedily re-
lieved this, leaving the neuralgia as intense as ever. After this
treatment he no longer endured such excruciating pain when in
a recumbent position. Up to this time no one had thought of
his trouble having any mechanical cause. It was looked upon
as a simple neuralgia. Later on, however, the symptoms began
to appear in the other leg, suggesting some common cause in
the abdominal region. A condition of hyperassthesia of the feet
and lower part of the legs began to trouble him. He could not
endure the lightest touch. The liniments applied hurt him
when first put on. Sometimes he complained of prickling pains
in the soles of the feet as if needles were being inserted. After
this cedema set in, beginning with the toes and working up both
limbs in a slowly progressive manner to a considerable distance
above the knees. The urine was carefully watched from time
to time for kidney trouble, but none was found. Constipation
was a constant symptom, and required continual attention. As
the trouble progressed the young man became less and less able
to move around, even with the aid of his crutches, and was at
last permanently confined to his reclining chair. To give him
some rest and change, Dr. Westbrook devised an adjustable cot
upon which he could be placed occasionally. From quite an
early date in his trouble the temperature kept above 101°, some-
times running as high as 103°. This suggested to Dr. Shaw
tuberculosis as a complication, but the post mortem did not con-
firm it. Before the speaker had called in Dr. Westbrook two
homoeopathic practitioners had been invited to see the patient
without his knowledge. Their diagnosis, as afterward discov-
ered, was aneurysm of one of the iliacs. They first heard the
distinct bruit which then appeared but afterward passed away.
The patient survived by several months the time they set for
his death. Up to and beyond this time every attempt at dis-
covering an enlargement by pressure through the abdominal
wall failed. A slight enlargement, however, did appear over
the right sacro-iliac synchondrosis looking more at first like an
cedematous spot than anything else. This gradually grew larger,
spreading toward the sacrum. From the time when the symp-
toms first appeared bilaterally until the tumor became too large
for its presence to be doubted, his diagnosis had hung between
disease of the sacro-iliac joint and sarcoma. Dr. Benjamin
Westbrook first demonstrated the presence of the tumor by
touching it through the rectum. The aneurysm theory of the
honKeopatbists was rejected by all the regular physicians who
saw the patient. Dr. Wight, some two months after Dr. West-
brook's examination, pronounced it osteo-sarcoma. The case
was a remarkable one in every way. It was treated by all sorts
of practitioners during some part of its career. Even the spirit-
ualists had a trial of their skill. The patient was an unusually
bright young man, a student of Columbia School of Mines, and
had just returned home from an extended tour in Egypt, Pales-
tine, and Central Europe, when he was attacked. He took the
Oriental trip because of ill-health.
Dr. Stub had not seen the case under discussion, but had
met with a similar one. A man had a slight sciatica ; after-
ward both legs were affected ; for a period of several weeks
he steadily persisted in efforts to walk in this condition. Then
he had to go to bed ; he could hardly shift his position in bed
without suffering excruciating pain; there was fever with loss
of appetite; he could not get up even with the aid of machines;
the pain only existed in the lower limbs. Dr. A. Jacobi came
over from New York and diagnosticated myelitis. The patient
was blistered and counter-irritated in various ways, and re-
ceived all kinds of medication. The diagnosis was adhered to,
until a movable tumor of the sacrum was discovered and a
diagnosis of cancer made. Subsequently there occurred what
was believed to be a general cancerous nodular infiltration.
Dr. Eccles stated that a diagnosis of myelitis had also been
made by the attending physician in the case reported by Dr.
Leuf, and adhered to almost to the last, although the physician
was acquainted witli the diagnosis of sacral tumor made by the
preceding attendants. We sometimes saw strange coincidences.
While he was in Europe the preceding summer, in Kilmaurs,
Ayreshire, Scotland, he met with the case of a young man of
about the same age as the patient whose case had been re-
ported, and with almost exactly the same history, who died at
almost the same time. There was no autopsy in that case.
The President said that there were two or three clinical
points in the case to which he would like to call attention. The
arterial bruit which had misled the so-called homoeopathic phy-
sicians was synchronous with the radial pulse, of about the
same character as the sound produced in an artery of medium
size by pressing upon it with the stethoscope, and audible over
the vertebral column from the upper dorsal to the upper sacral
region. He was unable to give any explanation of it, but
thought that no experienced auscultator should have mistaken
it for an aneurysmal bruit. The second fact of interest to the
clinician was the elevation of temperature which prevailed
throughout the time that he had had the patient under observa-
tion. It suggested the idea of vertebral caries, and the diag-
nosis, so far as he was concerned, had lain between caries and a
malignant tumor. After several aspirations of the swelling,
which occupied the sacral region, between the posterior spinous
processes of the ilia, more marked upon the right side, it was
pretty certain that there was no pus, for nothing but blood ever
appeared in the hypodermic syringe. At that time he was not
aware that sarcomatous growths gave rise to pyrexia, but he
had since seen an account of some observations by a European
physician, whose name had escaped his memory, which went to
show that this did occur. Palpation of the tumor through the
rectum had not been very satisfactory, as it could barely be
reached with the finger, and was too distant to be accurately
mapped out. He remembered a similar^case in which he had
made an autopsy for Dr. McCorkle and Dr. Barker, in which
also the growth had made its way through the greater sacro-
sciatic foramen. In that case there had been a sciatic neuritis,
presumably excited by the irritation from the pressure of the
growth, and the perineurium was thickened to such an ex-
tent as to enlarge the nerve to at least twice its ordinary dimen-
sions.
He had been informed by a credible person that, toward the
last, the unfortunate boy had been put under the care of a fe-
male whose method of treatment was to occupy the same bed
with the patient and impart to him some of her " vitality,"
" animal magnetism," or whatever she called it. This was, to
him, a new system of practice.
Dr. Stcb remarked that there had been an elevation of tem-
perature in his case.
The President thought that it might have been due to the
erosion of bone.
Dr. Eccles : " Isn't the age unusual ? "
Dr. Leuf : " For carcinoma it is, but for sarcoma it is not."
An Incompatible of Antipyrine. — Dr. Eccles announced
that some days previous, while making pharmaceutical investi-
gations, he had had occasion to mix some sweet spirits of niter
with a solution of antipyrine. At first the mixture was clear
and colorless, but, after some hours' standing, became green.
The optical appearances of this fluid were identical with those
of the anilines, and, as antipyrine was a coal-tar product, he
supposed the change was due to the formation of a green ani-
line, and so it had proved to be. This incompatibility was all
the more important as both substances were used for antipy-
retic purposes, and might be prescribed together.
Oct. 24, 1885.]
MISCELLANY.
473
HI i s 1 1 1 1 a it a .
The International Medical Congress. — In an editorial article en-
titled " A Medical Star Chamber," the " Boston Medical and Surgical
Journal " says :
"The Executive Committee of the committee appointed to arrange
for the meeting of the International Medical Congress in America in
1887 has recently held a meeting in New York city. An editorial in
the 'Journal of the American Medical Association' contains all the in-
formation concerning it that is made public. The little that is vouch-
safed us has certainly the merit of exciting curiosity as to what has
been left untold. To prevent all further misunderstanding, both at
home and abroad, the committee unanimously adopted the following
declaration of independence : ' That the actions of this Executive Com-
mittee are final, not being subject to revision, amendment, or alteration,
by either the Committee of Arrangements or the American Medical As-
sociation.' How will the Committee of Arrangements and the Ameri-
can Medical Association like that ? The opinion of Mr. Randall, deliv-
ered no longer ago than last May, was urged in support of interference
with the original committee for alleged too great independence of
action. If of force at that time it is equally good authority at present-
'I might add, in addition,' said Mr. Randall, 'that the theory that a
select committee created by a body with certain defined powers and
duties gives any vested rights — so to speak — which places it above or
beyond the power of the creating body to review or regulate, is one not
only without precedent in parliamentary law, practice, or history, but
is untenable on any ground of parliamentary principle.' Prof. Frederic
S. Dennis was appointed Associate Secretary-General, and another was
appointed Chairman of the Finance Committee. Why another's name
should be concealed from an anxious public we can only conjecture. Is
the anonymous gentleman too modest to allow his name to appear ? Is
some nameless individual to assume the expenses of the Congress ? Is
secrecy necessary as a safeguard against theft, or is the committee
ashamed of its appointment ? It must be a very bad choice indeed
which can be worse than such ostentatious secrecy. It would seem as
though this branch of the enlarged committee was bound to destroy
what little respect was left for the proposed International Congress."
The same journal publishes the following letter from Dr. Henry I.
Bowditch :
"Boston, October 8, 1885.
"Mr. Editor: Since Dr. J. S. Billings, as general secretary of the
committee for arranging the International Congress for 1887, informed
me that I was selected as one of the vice-presidents of the Congress, I
have had no official notice either of my summary displacement by the
new committee at its meeting in Chicago (June 24th) or of my reinstate-
ment by the same committee (September 3d). For this and other rea-
sons to be named, I ask a place in your journal for the following state-
ment : When urged by some friends to sign the protest made in several
cities by gentlemen opposed to the action taken at New Orleans, I re-
plied, ' It would be absurd for me to do so, because the committee has
already expelled me from office.'
" Since that time I have watched with interest the course pursued
by the ' Journal of the American Medical Association,' and also that
of the new committee for the International Congress. I have read with
pain the perpetually recurring bitterness and insinuations against all
those who had dared to express opinions adverse to the doings of the
association, or those of its new committee. I was surprised and dis-
gusted while reading the editorials of August 1st, entitled ' The Inter-
national Medical Congress and its Enemies,' and that of August 29th,
'International Medical Congress of 1887 and the American Medical As-
sociation.' From these editorials any foreigner reading them would
not have the least suspicion that the controversy on the ' code ' had any
share in the imbroglio at present existing. I wholly deny that those
who now disapprove of the course the association and its committee
have taken are the 'enemies of the International Congress.' On the
contrary, they are, in my opinion, its best friends.
" Notwithstanding my objection to such editorials, I have continued
to decline to sign the protest in the hope that, by so acting, I might
perchance do something toward the promotion of professional harmony
in America.
" But the last manifesto of the committee and gross assumption of
despotic power for making all future arrangements for the Congress
(vide ' Executive Committee of the Ninth International Congress,' ' Jour-
nal of the American Medical Association,' September 3d) convince me
that I can remain no longer in the position in which the new commit-
tee (as I learn from the journals) placed me without my knowledge or
consent at their meeting in September.
" That manifesto by the new committee is equaled by nothing in
the history of medicine in this country, save the arrogant position
taken by the Judicial Council of the American Association at its meet-
ing in Cleveland in 1883. The Council, through its chairman, declared
that the Council ' took the responsibility ' of requiring every member
to sign annually the code of ethics, or to lose his right to meet his fel-
lows at the gatherings of their association for the advancement, of the
sacred cause of Medical Learning !
" That decision of the Council was disgraceful alike to the Council
as declaring its assumption of power which it did not legally possess,
and to the association for its pusillanimity in submitting, even to the
present day, to the insult then inflicted upon it — a so-called scientific
and learned body.
"To one who looks behind the scenes and knows whose intellectual
power, combined with honest but misguided bigotry, has influenced the
Council of the American Association, there is no difficulty in understand-
ing the present position of the ' Committee for the International Con-
gress.'
" The same dominant mind governs both. I loathe all such un-
generous and bigoted work, and therefore retire from office in the same
public manner that I have been placed there. In declining thus pub-
licly the honor it would confer on me, I am only imitating the example
set by the committee in its intercourse with me.
" Respectfully yours,
" Henry I. Bowditch, M. D.
" P. S. By a singular coincidence I have received to-day, since the
above was in type, from the chairman and secretary of the committee,
official notice of my appointment to the office of vice-president of the
International Congress. Upon mature reflection I can not alter my
decision as above given."
The " Medical News," of Philadelphia, announces the declinations of
Dr. Henry F. Campbell, of Augusta, Ga. ; Dr. E. 0. Shakespeare, of
Philadelphia; Dr. Henry G. Beyer, of the navy; Dr. John J. Mason, of
Newport, R. I. ; Dr. Jerome H. Kidder, of Washington ; and Dr. J. M.
Flint, of the navy.
Editorially, the " News " says :
" In the beginning of the Congress controversy extreme solicitude
was expressed by some members of the association for the assertion of
its supreme authority in everything pertaining to the organization of the
Washington meeting, and its journal devoted many pages to advocating
this point." Now, however, that the new Executive Committee has pro-
claimed its independence of the parent committee and of the association,
by formally declaring that its acts are ' not subject to revision, amend-
ment, or alteration by either the committee of arrangements or the
American Medical Association,' the journal has not a word to say
against their usurpation of power, or about the propriety now of main-
taining the authority of the association in the premises. It does not
point out how the new committee have laid themselves open to ' the
charge of having ignored the body from which its existence and all its
powers had been derived,' or how they ' coolly turn the association into
a " foot-ball " and contemptuously kick it out of their way.' It no longer
talks about members making ' a bold attempt to use the national char-
acter and prestige of the American Medical Association as a " decoy
duck " to obtain their own appointment to office.' The authority of the
association is openly defied by its own committee, and its journal sud-
denly becomes silent on the subject."
The " Pacific Medical and Surgical Journal," of San Francisco, closes
an editorial article as follows :
" The American committee had one chance to retrieve itself, but
that is past, for it has ignored the representations of the profession,
both in Europe and our own country. Now we shall have no compro-
474
MISCELLANY.
[N. Y. MkI>. Jr.TH.,
mise. Those blatant notoriety hunters, with the impudence which has
characterized them from the very commencement of their action at
New Orleans, have endeavored to carry out their plans in defiance of
the wishes of the professional world, and to the disgrace of their own
country. They have shown themselves to be utterly regardless of every-
thing but vainglory. Through a premeditated and carefully arranged
plan, suddenly sprung upon the association, they jumped into a position
of power, and that power they have abused until their very names are
becoming execrable in the ears of their countrymen. The profession
must either indorse the action of Dr. Billings's committee, or request
that the Congress be held in some other country, and we advise our
brothers to withhold all subscriptions until one or other of these con-
clusions has been adopted. In the event of no action being taken in the
matter, then let those men play at having a congress, and handle their
puppets like any other showmen ; but never let the American nation
forget "itself so far as to countenance such mimicry as a national event."
Regulations for the Maintenance of Quarantine Inspections on the
Northern Frontier of the United States.— The following circular, dated
October 10th, has been issued by Surgeon-General Hamilton :
To the Medical Officers of the Marine-Hospital Service,
Customs Officers, and others concerned:
The act approved April 29, 1878, entitled "An Act to prevent the
introduction of contagious or infectious diseases into the United States,"
provides that no vessel or vehicle coming from any foreign port or
country where any contagious or infectious disease exists, or any vessel
or vehicle conveying persons, merchandise, or animals affected with any
contagious disease, shall enter any port of the United States, or pass
the boundary-line between the United States and any foreign country,
except in such manner as may be prescribed under said act.
Attention is now directed to the prevalence of the contagious and
infectious disease of small-pox in Montreal and other places in the
Dominion of Canada, and the law referred to is held to apply alike to
trains of cars and other vehicles crossing the border and to vessels
entering ports on the northern frontier.
Because, therefore, of the danger which attaches to the transporta-
tion of persons and baggage, and articles of merchandise, or animals,
from the infected districts, the following regulations are framed, under
th« direction of the Secretary of the Treasury, and subject to the ap-
proval of the President, for the protection of the health of the people
of the United States against the danger referred to :
1. Until further orders, all vessels arriving from ports in Canada,
and trains of cars and other vehicles crossing the border-line, must be
examined by a medical inspector of the Marine-Hospital Service before
they will be allowed to enter the United States, unless provision shall
have been made by State or municipal quarantine laws and regulations
for such examination.
2. All persons arriving from Canada by rail or otherwise must be
examined by such medical inspector before they will be allowed to
enter the United States, unless provision has been made for such ex-
amination as aforesaid.
3. All persons coming from infected districts, not giving satisfac-
tory evidence of protection against small-pox, will be prohibited from
proceeding into the United States until after such period as the medical
inspector, the local quarantine, or other sanitary officer duly authorized,
may direct.
4. The inspectors will vaccinate all unprotected persons who desire,
or are willing to submit to, vaccination free of charge. Any such per-
son refusing to be vaccinated shall be prevented from entering the
United States.
5. All baggage, clothing, and other effects, and articles of mer-
chandise, coming from infected districts, and liable to carry infection, or
suspected of being infected, will be subjected to thorough disinfection.
6. All persons showing evidence of having had small-pox or vario-
loid, or who exhibit a well-defined mark of recent vaccination, may be
considered protected, but the wearing-apparel and baggage of such pro-
tected persons who may come from infected districts, or have been
exposed to infection, will be subjected to thorough disinfection as above
provided.
1. Customs officers and United States medical inspectors will con-
sult and act in conjunction with authorized State and local health au-
thorities so far as may be practicable, and unnecessary detention of
trains or other vehicles, persons, animals, baggage, or merchandise, will
be avoided so far as may be consistent with the prevention of the intro-
duction of diseases dangerous to the public health into the United
States.
8. Inspectors will make full weekly reports of services performed
under this regulation.
9. As provided in Section 5 of said act, all quarantine officers or
agents acting under any State or municipal system, upon the applica-
tion of the respective State or municipal authorities, are empowered to
enforce the provisions of these regulations, and are hereby authorized
to prevent the entrance into the United States of any vessel or vehicle,
person, merchandise, or animals prohibited under the act aforesaid.
10. In the enforcement of these regulations there shall be no inter-
ference with any quarantine laws or regulations existing under or to be
provided for by any State or municipal authority.
The Transportation of Dead Bodies. — At a recent meeting of the
Michigan State Board of Health the secretary reported that, by invita-
tation, he had attended, September 16th, in Lansing, a meeting of the
Michigan Association of General Baggage Agents, and taken part in the
discussion of the subject of the meeting, " The Transportation of Dead
Bodies." At that meeting a committee was appointed to draft rules
for the guidance of agents of railroad companies in the transportation
of dead bodies. The chairman of that committee, Mr. H. P. Dealing,
the general baggage agent of the Michigan Central Railroad, appeared
before the board and presented the rules as adopted by the committee.
He said the design was to make a set of rules that would meet the views
of the several State boards of health, and be adopted by all the great
lines of railroad in the United States, so that there should be uniformity
of practice, thus better protecting the lives of railroad employees and
those of travelers. Rule 1 absolutely prohibits the transportation of
bodies dead from small-pox, Asiatic cholera, typhus fever, and yellow
fever. Rule 2 provides that all other dead bodies may be transported,
provided they are incased in an antiseptic interment sack, hermetically
sealed, in addition to being in a coffin, and this in a tight wooden box,
except those dead of diphtheria, scarlet fever, typhoid fever, erysipelas,
measles, or other contagious and infectious diseases, which must be
wrapped in a sheet thoroughly saturated with a strong solution of chlo-
ride of zinc (one half pound of the chloride of zinc to a gallon of water)
before being incased in the hermetically-sealed sack. The coffin must
be surrounded by sawdust saturated with a solution of chloride of zinc
of the same strength. Rule 3 specifies that no person or article that
has been exposed to the infection may accompany the body. Rule 4
provides that some one must accompany the body ; and forms for cer-
tificates are given. After discussion of the subject, the board ap-
proved of the rules.
The American Academy of Medicine. — At the ninth annual meet-
ing, to be held at the New York Academy of Medicine, on Wednesday
and Thursday of next week, papers are expected to be read as follows :
" The Study of Medicine as a Means of Education," by Dr. Robert
Lowry Sibbet, of Carlisle, Pa. ; "Medical Supervision in Student Life,"
by Dr. Charles Mclntire, of Easton, Pa. ; "Western North Carolina as
a Health Resort," by Dr. Henry 0. Marcy, of Boston ; " The Impor-
tance of Climatology considered as a Regular Branch of Study in Medi-
cal Colleges," by Dr. E. H. M. Sell, of New York ; the president's ad-
dress, entitled "What is Medicine ?" by Dr. Albert L. Gihon, of the
navy; "Medical Evidence," by Dr. Thomas J. Turner, of the navy;
" Report on Laws regulating the Practice of Medicine in the United
States and Canada," by Dr. Richard J. Dunglison, of Philadelphia, and
Dr. Henry 0. Marcy, of Boston; "Health Officers, Ancient and Mod-
ern," by Dr. Benjamin Lee, of Philadelphia; "Micro-organisms and
their Relation to Disease," by Dr. Samuel N. Nelson, of Cambridge,
Mass. : " Observations on the Relation of Bacteria to certain Puerperal
Inflammations," by Dr. Ernest W. Cushing, of Boston ; " Medical Li-
censes and Medical Honors," by Dr. Edward Jackson, of Philadelphia ;
" The Physician and his Patient," by Dr. John Devin Kelly, of Utica,
N. Y. ; " Physicians of Delaware in the Eighteenth Century," by Dr.
Lewis P. Bush, of Wilmington, Del.
Oct. 24, 1885.]
MISCELLANY.
475
Georgetown University. — The Washington correspondent of the
Philadelphia " Medical News " says that, at the time that Surgeon-
General Hamilton, of the Marine-Hospital Service, handed his resigna-
tion to the President, he also resigned the professorship of surgery in
the Medical Department of Georgetown University. It was accepted
with reluctance, and ex-Surgeon-General Wales, of the navy, was finally
appointed to the vacancy. When, however, it was learned that the
President would not accept Dr. Hamilton's resignation, Dr. Wales at
•once resigned the professorship, whereupon Dr. Hamilton was re-elected
to the chair.
Diphtheria of the (Esophagus. — Dr. H. D. Fry, of Washington
(" Am. Jour, of the Med. Sci."), contributes an interesting study of this
rare affection, and reports a case which occurred in his own practice.
The diagnosis of diphtheria of the oesophagus is extremely difficult. In
most cases it is absolutely impossible to recognize the disease. This
difficulty is met with not only when the oesophageal mucous membrane
is primarily the seat of diphtheritic inflammation, but also when it is
implicated by extension of the false membrane from the pharynx or
larynx. In the vast majority of the reported cases its presence was not
suspected until revealed by post-mortem examination. Symptoms, at
most, only warrant a suspicion of the existence of the affection. An
important indication is the expulsion, by the mouth, of bands of false
membrane, provided no symptoms exist to indicate that the air-passages
are involved. The expectoration of a membranous cast of the oesopha-
gus is the only positive sign of the disease. The obscurity which ac-
companies nearly all affections of the oesophagus is well illustrated by
the experience of Steffen. Out of forty-four cases, including diph-
theria, hyperasinia, catarrhal inflammation, ulceration, ecchymosis, and
gangrene, the diagnosis was made in only three ; the remainder were
found on post-mortem examination. Dr. Fry concludes his paper with
a careful analysis of the symptoms which were observed in the twelve
cases which he has been able to find fully reported in literature.
The Limitations of Colotomy in Disease of the Rectum. — Dr. Charles
B. Kelsey, of New York (Ibid.), defines the following as the indications
for colotomy : 1. In congenital malformations of rectum or anus in
children in which a tentative operation in the perineum has failed to
reach the rectal pouch. 2. In intestino-vesical fistula?. 3. In tumors
occluding the rectum which can not be relieved by any other means —
dilatation, division, hot water, or electrolysis. 4. In non-cancerous,
simple, or specific stricture and ulceration of the rectum (with or with-
out fistula1), where the disease can not be relieved by proctotomy or
dilatation, or division of the fistula; and local treatment of the ulcera-
tion. 5. In cancer where the disease can neither be removed nor the
passage re-established, and where death is probable from obstruction —
except in cases where the immediate dangers of the operation more
than counterbalance any good likely to be gained by it. 6. In volvulus
or intussusception of the colon or sigmoid flexure, where reduction by
the aid of laparotomy has been found impossible.
The Choice of Methods in Abdominal Delivery. — Gastro-hysterotomy
has been improved by the introduction of the uterine suture, and lives
have been saved that must otherwise have been lost ; but no change in
the old operation can compensate for the delay and intermeddling so
generally indulged in (where the knife is the only remedy that promises
success), to the fatal termination of the case. In an instructive arti-
cle, Dr. R. P. Harris, of Philadelphia (Ibid.), shows that it is in vain to
practice this operation in the United States unless it is done in good
season. Since January 1, 1875, 29 out of 38 cases have ended fatally,
and 21 children were extracted dead, leaving 17, of whom 4 soon per-
ished from causes occurring before delivery. Twenty-eight women were
in labor from one day to two weeks, and fifteen of them more than
three days. The Sanger modification with its simplifications has been
performed 12 times, saving 6 women and 10 children, of which 5
cases belong to the credit of Dr. Leopold, of Dresden, who saved 4
women and 5 children. Of 8 German cases, 6 ended in recovery.
These women were in labor respectively 12 hours, 8, 30, " some hours,"
and 10 hours, and in 1 case the time was not mentioned. The women
whose cases were marked "favorable" by reason of their condition
before the operation all recovered. A tabular record of cases is given
by Dr. Harris.
Laparo-elytrotomy also numbers 12 cases, with 6 recoveries and 7
children saved. Nine of the cases belong to New York city and Brook-
lyn, where 6 women and 5 children were saved. These 6 women were
in labor respectively 11 hours, 4 days, 16 hours, a week, 8 hours, and
22 hours. There were 4 "favorable" cases among the 12, all of which
ended in recovery. These two cities have a credit of 11 Cesarean
operations, saving but 2 women and 2 children. In 10, the prognosis
was "unfavorable." In cases made more serious by delay, laparo-ely.
trotomy promises better than gastro-hysterotomy, and should be pre-
ferred to it. It also promises more favorably for British cases, so far
as we can judge by New York, where the mortality was formerly equal
to that of England. A table of the operation is given.
The Porro-Caesarean operation, Dr. Harris shows, is par excellence
the method for hospitals, where the women should be under anticipative
treatment and operated upon very early in, or just prior to, labor. The
Muller modification is preferable where the placenta is upon the ante-
rior uterine wall, or the foetus dead and putrid. Dwarf subjects require
that the delivery under the knife should be effected very early, as ex-
haustion occurs after a short effort of nature, and death is apt to result
in such cases. The Porro operation has been the most successful in
the cases of dwarfs.
The Causal Relation of Obstructed Cardiac Circulation to Lymph
Stasis. — In a learned article, Dr. S. C. Busey, of Washington (Ibid.),
points out that retardation, or arrest of the current of the fluid in the
thoracic duct at or near its outlet into the subclavian vein, may produce
dilatation, distension, and rupture of lymphatic vessels, and consequent
effusion of chyle and lymph into the serous cavities. The remoteness
of the effects from the obstacle interrupting the current of the fluid
may depend upon various concomitant conditions, especially upon the
anatomical integrity and the distensibility of the vascular walls. When
the impediment to the flow of chyle and lymph occurs at or near its
outlet, the area of stasis and ectasis will necessarily depend upon the
duration and extent of such obstacle ; and hence, when the area of
ectasia is extensive, the manifest inference is that the cause has been
one of gradual development and protracted duration. The influence of
partial obliteration or stenosis of the thoracic duct at or near its termi-
nation in the causation of dilatation or rupture of some part of the
lvmph-vascular system can not be doubted. The evidences of experi-
mentation must be accepted as conclusive. The effects of stenosis
produced by the gradual encroachment from disease of the duct or of
surrounding and contiguous tissues and structures are shown by clinical
and post-mortem citations. In this latter class of cases the ectasia is
gradual in its development and more extensive in its field. In cases
where the lymphangiectasis was consequent upon the slowing or inter-
ruption of the venous blood-current in the left subclavian vein, the rela-
tion of cause and effect seems equally well established. Dr. Busey
shows that such diseases of the heart as slow, impede, or stagnate the
venous blood-current in the left subclavian or innominate vein may
also produce lymph-stasis.
The Predisposing Causes of Aneurysm. — In a valuable paper Surgeon-
General Hamilton (Ibid.) presents an elaborate study of the predisposing
causes of aneurysm. So far as his inquiry has extended, the only con-
stant element among all the alleged causes of aneurysm is that of climate.
Neither syphilis, nor alcoholism, nor occupation, nor heat, alone, ap-
pears to have an appreciable influence on the causation of this disease.
As to how far the influence of diet may extend in the production of
aneurysm he has been unable to form any conclusion, but it is possible
certain kinds of food may have a powerful influence.
The Academy of Medicine's Section in Practice of Medicine held
a regular meeting on Tuesday evening, the 20th inst., at which Dr.
Laurence Johnson read a paper on " The Choice of Remedies," and a
general discussion took place on the question, Is Typhoid Fever ever
of Spontaneous Origin ? " We would suggest that a somewhat closer
approach to accuracy in the cards of announcement would not be amiss.
On the card announcing that meeting Dr. Laurence Johnson figures as
Dr. Lawrence Johnson, Dr. W. II. Thomson as Dr. W. II. Thompson,
Dr. J. Haven Emerson as Dr. F. Haveu Emerson, and Dr. S. Oakley
Van dcr Poel as Dr. J. Oakey Vanderpoel.
476
The Brooklyn Pathological Society. — Dr. Daniel Ayres will deliver
his secoud lecture on " The Pathology of the Inflammatory Process " at
the next meeting of the society, to be held at the Brooklyn Eye and Ear
Hospital on Thursday evening, the 29th inst.
The New York Academy of Medicine. — At the meeting of the
Academy held on Thursday, the 15th inst., Dr. F. A. Castle, the treas-
urer of the Board of Trustees, reported the fiual payment of two thou-
sand dollars on the mortgage on the Academy's property. This leaves
the Academy entirely free from debt.
THERAPEUTICAL NOTES.
The Use of Iodoform Collodion, especially in Neuralgia. — Dr.
William Browning, of Brooklyn (" Am. Jour, of the Med. Sei.") gives
his experience with this remedy for external application, together with
notes on the preparation itself, and a brief study of its action. The
strength usually employed is one part of iodoform to fifteen of collo-
dion. Half an ounce is usually sufficient for a single application. Dr.
Browning has found it most effective when painted on in very thick
layers, which may be conveniently done with the usual camel's-hair
brush. As soon as one coating becomes a little firm another is applied,
and so on until it appears to have an average thickness of i mm. In
the neuralgic cases a cure, when effected, was usually accomplished
with one or two applications. The troubles found most amenable to
this treatment were narrowly localized neuralgias, especially when cor-
responding to some particular nerve and not dependent on any demon-
strable lesion. In fact, if a neuralgia, or what is thought to be one,
proves intractable to this means, we should doubt its being a purely
functional affection, and look carefully for some tangible cause. It has
thus a certain diagnostic, as well as a therapeutic, value. Several times
its complete or partial failure has led to a more searching and success-
ful examination. Even in such cases much temporary relief is often
afforded. Supra-orbital neuralgias, even of malarial origin, particularly
if the miasmatic infection dates back some time, seem quite amenable
to this treatment. It is not recommended as a substitute for the use
of quinine, but only as an adjuvant where the latter fails or acts too
slowly.
The Use of Strychnine in Nervous Disease. — Dr. Landon Carter
Gray, of Brooklyn (Ibid.), reports five cases which show that strychnine
was not well borne in two cases of severe acute myelitis, or in two cases
of subacute poliomyelitis; that doses of ^ of a grain, continued for
four days, three months after the onset of transverse myelitis with
early extension to the lateral columns, suddenly induced alarming
symptoms of poisoning ; that one patient with chronic general myelitis
of traumatic origin was greatly benefited, as was likewise one with gen-
eral myelitis in which the onset had been gradual ; that in five cases of
progressive muscular atrophy it acted remarkably as a stimulant ; and
that, as Dr. Weir Mitchell has indicated, it was decidedly beneficial to
persons with neurasthenia who, after eight or ten weeks' treatment
with rest and forced feeding, were taken out of bed, although it failed
to agree with three subjects of the same affection treated in the ordi-
nary way.
The Treatment of Extra-uterine Pregnancy with Electricity. — Dr.
Henry G. Landis (Ibid.) remarks that it may be regarded as proved that
electricity in some form is a specific cure for extra-uterine pregnancy.
It arrests the growth and destroys the vitality of the embryo and cyst,
and its use is followed by a truly remarkable disappearance of all or
the greater part of the growth in a short time. This at least is true when
the electricity is used during the first half of the pregnancy. As we ap-
proach the period of viability in the child the risk of rupture of the cyst
diminishes, and the propriety of surgical interference at or near term
becomes greater. The great advantage of the faradaic current over all
other forms of electricity has been shown, but opinion is not yet set-
tled as to whether we should use a local current for a long time or a
strong current briefly, and how many repetitions of the application are
necessary. To determine these points, Dr. Landis has conducted a
series of experiments based upon the supposition that success is
achieved by the death of the embryo, the specific value of the method
being that the foetus will surely be killed if it gets a large enough dose
of the current. The experiments are also based upon the supposition
[N. Y. Mud. Jodr.
that the foetus is in the matter of vitality to be compared with some of
the lower forms of life. Dr. Landis draws the following conclusions:
1. In using the faradaic current in extra-uterine pregnancy, the appli-
cations should be protracted for an hour, if the patient can bear it. 2.
The current should be repeatedly applied, in order that the vitality of
the foetus may be finally exhausted. 3. The current should be used in
great strength for at least one sitting. 4. The current probably acts,
not only by destroying the foetus, but by its action upon the placental
circulation; an additional reason for a long application.
Bismuth as a Dressing for Wounds. — M. Gosselin and M. Heret
("Progr. med.") have been studying the mode of action of subnitrate
of bismuth upon wounds. It is known that this drug has the effect of
diminishing the oozing of blood after an operation. Although, in itself,
it has no coagulating power, it acquires such a property by virtue of
the disengagement of nitric acid upon the mouths of the capillaries.
Moreover, it lias an astringent action, due at the same time to the nas-
cent nitric acid and to the oxide of bismuth, a germicidal effect, and a
special sedative operation. The subnitrate should be preferred, as the
other salts have not, of course, the coagulating and constrictive power
that is due to the acid. It may be used either in powder or by irriga-
tion in the proportion of 1 to 50.
Formulae for the Use of Iodoform. — "Nouveaux remedes" quotes
the following formula; from the "Courtier medical":
An Injection for Chronic Catarrh of the Bladder, Urethritis, etc. —
Iodoform 1 part ;
Glycerin 5 parts;
Distilled water. . 100 "
For Hypodermic Injections in Syphilis. —
Iodoform 1 part ;
Sulphuric ether, i
r.v ., - each 5 parts.
Olive-oil, \
For Internal Use in Convulsions. —
Iodoform 18 grains;
Iodide of potassium 1 drachm;
Red wine 2f drachms.
From three to fifteen drops are to be given, in a glass of wine, three
times a day.
Pills for Bronchitis and Emphysemei. —
Iodoform Ingrain;
Lycopodium 6 grains ;
Extract of phellandrium 15 "
Divide into ten pills. From three to five to be taken daily.
Chloroform in the Treatment of Post-partum Haemorrhage. — Dr.
F. Betz (" Memorabil.") was lately led by Robinson's reports of the effi-
cacy of alcoholic injections into the uterus to try the effect of inserting
a sponge saturated with chloroform. Severe burning pain was at once
produced in the whole parturient canal, but brisk uterine contraction
supervened promptly, and the bleeding was stopped. In another case
he pressed against the cervix a tampon moistened with a mixture of
chloroform, sulphuric ether, and a little acetic ether. The same results
followed. The styptic action, he remarks, is wholly due to muscular
contraction, and not at all to the coagulation of blood.
Belladonna as an Adjuvant to Iodide of Potassium. — Aubert (" St.
Petersb. med. Wchnschr." ; " Memorabil.") states that the use of bella-
donna prevents the unpleasant effects sometimes produced by iodide of
potassium on the naso-pharyngeal mucous membrane. Three quarters
of a grain of extract of belladonna, in pill form, given with the iodide,
are sufficient, and the use of the adjuvant need not be continued long,
for after a short time the disposition to the unpleasant effects referred
to disappears and does not return.
Antimony in the Treatment of Psoriasis. — Mr. James Mason
(" Glasgow Med. Jour.") says that in some of the most inveterate cases
antimony " acts like a charm," causing a rapid disappearance of the
scaling. He alludes to the case of a man whose face and head became
almost entirely free from scales after a week's use of five-minim doses
of wine of antimony. The author adds that the antimonial treatment
of psoriasis has been practiced for several years by Dr. Cavafy, of St.
George's Hospital, London.
MISCELLANY.
THE KEW YORK MEDICAL JOURNAL, October 31, 1885
$righral (ffommniucatians.
A CONTRIBUTION TO THE
TREATMENT OF CERTAIN FRACTURES
OF THE
BONES OF THE LEG, AND OF THE PATELLA,
BY DRILLING AND WIRING OF THE FRAGMENTS*
By J. WILLISTON" WRIGHT, M. A., M. D.,
>ROFESSOR OP SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY
OP THE OITY OP NEW YORK ; VISITING SURGEON TO BELLEVUE HOSPITAL,
ETC.
Mr. President and Gentlemen : The following five
jases of compound fracture of the bones of the leg, to-
gether with three of simple fracture of the patella, which I
lave treated during the past three years by drilling and
wiring of the fragments, are presented, not so much, with
the view of taking a new departure in the management of
this class of injuries as for the purpose of inviting a dis-
jussion of the subject at large, and with the object of
determining, as far as may be from a limited amount of
material, whether the method by wiring in the worst cases
of compound fracture of the leg, and in certain exceptional
cases of simple fracture of the patella, to which the plan
has been restricted in my own practice, possesses any advan-
tages over the older and more usual means of treatment,
either in the way of greater safety to life, additional oppor-
tunities for avoiding an amputation, primary or secondary,
in favoring the reparative processes, or, finally, in the direc-
tion of a saving of time and a mitigation of suffering for
the patient.
Case I. — John Sheridan, Irish, liquor dealer, aged twenty-
seven, healthy.
February 6, I884. — Was injured by street-car this morn-
ing, the wheels passing obliquely over the right leg near the
knee. Compound fracture of the tibia, two inches below the
tubercle, associated with a contused and lacerated wound, four
inches long, extending upward and inward from the seat of
fracture. Fracture exposed, under bichloride irrigation, by an
incision four inches long, made parallel with the crest of the
tibia, and communicating with the original wound. The frac-
ture was found to be oblique from above downward and from
within outward. Deep pockets, filled with coagulated blood
and sand, extended upward in the subcutaneous tissue to above
the knee joint, and downward for a distance of four or five
inches. The fascia of the leg was extensively lacerated, the
tibialis-anticns muscle badly torn and contused, and the peri-
osteum stripped from the fragments of the bone for some dis-
tance.
The blood-clots, sand, and shreds of tissue were removed by
washing, scraping, and the use of the scissors ; the fragments
drilled and wired together with a double strand of No. 26 sil-
ver wire.
The wounds were closed with carbolized catgut sutures ; the
pockets drained with rubber tubes through counter-openings;
the limb was dressed antiseptically, and suspended in a cradle
made of heavy wire netting.
18th. — Highest temperature since the operation 100-6°, and
din ing the last week it has been normal. No pain. Dressing
* Head before the New York Clinical Society, April 24, 1885.
changed to-day for the first time (twelve days). No pus in the
dressings. The incision made with the knife has healed through-
out by first intention ; a small linear dry slough is found on
one edge of the original wound, where the skin was much con-
tused ; there is no swelling, no inflammation, and the leg looks
remarkably well; drainage-tube removed, and the limb dressed
as at first. From this time all went well ; the remainder of the
wound cleaned, granulated, and healed kindly, and the patient
was discharged June 2d (sixteen weeks after the injury) with no
shortening or other deformity, and able to walk well. Patient
seen April 23, 1885, and says his injured leg is "nearly as
good as ever."
Case II. — Nellie Murphy, Irish, tailoress, aged thirty, good
health.
Her left knee has been partly flexed and ankylosed for sev-
eral years past, due to an old synovitis.
February 15, 1884- — Fell down stairs to-day and sustained a
fracture of the left tibia just below the tubercle, compounded
by an opening in the skin one inch in length ; fracture slightly
oblique, with considerable displacement of fragments. Another
simple fracture of the same bone was discovered at the junction
of the lower and middle third.
16th. — Under bichloride irrigation, an incision, three inches
long, was made at the seat of the upper fracture, over the crest
of the tibia.
The soft parts were not seriously lacerated, but considerable
dissection of the connective tissue had taken place from a large
amount of effused blood.
The wound was thoroughly cleared of clots and cleansed ;
the fragments were drilled and wired as in Case I. Wound
closed with catgut, drained through counter-opening ; limb
dressed antiseptically and suspended.
In this case I ventured to predict delayed union of the
upper fracture on account of its locality and from the fact
of its being complicated by another fracture lower down,
my experience in similar cases having taught me that any
fracture at the upper end of this bone is less likely to unite
promptly, cceteris paribus, than one in the middle of the
shaft, due, probably, to its greater distance from the princi-
pal trunk of the nutrient artery ; and, furthermore, that when
a multiple fracture is present, the one which is nearest to
the nutrient foramen will be the first to unite ; or, in other
words, the lower fracture, under these conditions, seems to
appropriate to itself whatever reparative material is brought
to the injured bone through this channel, leaving the upper
fracture mainly dependent upon the small vessels which
have first ramified in the periosteum before entering the
bone.
11th — Temperature 101 -4°.
26th. — Temperature normal since last report. Dressings
changed to day for the first time (eleven days). No pus;
wound healed ; tube removed and new dressing applied.
March 15th. — Dressing removed ; union of fractures not
firm ; plaster splint applied.
Subsequent History. — The lower fracture united with slight
deformity, owing to the impossibility of keeping the lower end
of the middle piece in position, in about the usual time ; but the
union of the upper fracture was delayed for many weeks.
Patient discharged July 20th (five months after the wiring),
able to support the weight of the body on the limb.
November 20th. — Union not absolutely perfect, but patient
able to walk well by the aid of a cane.
478
WRIOET: TREATMENT OF FRACTURES OF THE LEO AND PATELLA. [N. Y. Med. Joub.,
Case III. — Thomas Rafferty, Irish, laborer, aged forty-three,
healthy.
July 21, I884. — To-day, while working in a quarry, a heavy
stone tell from a derrick, striking an iron bar which he held in
his hand, and driving it, with great force, against his right leg.
On examination, I found a small incised wound at the junction
of the lower and middle third, on the inside of the leg, which
communicated with a fracture of the tibia, and also with a large
hematoma extending from the wound to below the internal
malleolus. The patient had lost much blood and was still bleed-
ing freely. Under irrigation, an incision was made, beginning
two inches above the wound and curving downward to include
it and the hematoma, four or rive inches in length.
The fracture of the tibia was found to be oblique from above
downward, forward, and inward, with some comminution of
the bone ; one fragment, one inch and a half in length, and sev-
eral smaller ones were removed. The internal malleolus was
denuded, bruised, and roughened; the sheath of the tibialis-
posticus muscle was opened and the muscle itself badly torn ;
the connective tissue was lacerated and extensively infiltrated
with blood; the fibula was fractured higher up, but not com-
pounded.
The wound was cleansed, the haemorrhage controlled, the
fragments drilled and wired with heavy copper wire coated
with silver, and the limb dressed like the others.
August 2d. — Highest temperature since the operation 100-8*.
11th. — First dressing to-day (twenty days). Wound healthy
and healing, with the exception of a small dry slough at the
center of old hematoma.
30th. — Redressed. Slough separated and wound nearly
healed.
September 6th. — Wound healed and plaster splint applied.
24th. — Plaster splint removed ; found twisted portion of
wire protruding through a small ulceration of the skin ; wire
cut and removed ; union not firm ; percussed the bone above
and below the seat of fracture with small rubber mallet. This
was followed by a mild attack of simple cutaneous erysipelas,
lasting two weeks, at the end of which time the union was
found to be firm and bony.
Patient discharged, March 29th (eight months from the date
of the injury), with good union of the fracture, but with some
stiffness of the ankle joint, due chiefly to his great timidity in
using the limb.
Case IV. — Henry Hall, American, wall-paper maker, aged
forty-six ; healthy.
February 22, 1885. — Fell in the street to-day while intoxi-
cated and sustained a compound fracture of both bones of left
leg, about three inches above the ankle joint. The fracture of
the tibia was very oblique from above downward and inward,
the fractured surfaces being four inches long and the ends of
the fragments very sharp. Two small wounds of the skin,
caused by puncture of the upper fragment, were found on the
inner side of the ankle just above the malleolus. Under irriga-
tion, an incision, five inches in length, was made to expose the
fracture. There was much overriding of the fragments, and
great difficulty in effecting reduction, even with the patient pro-
foundly under the influence of ether, and it was impossible to
maintain apposition except by powerful extension and counter-
extension. A bleeding vessel of some size, probably the inter-
nal malleolar, was ligated. The fragments were then drilled
and wired in two places with heavy silver wire. Dressing and
after-treatment like the others.
March 16th (twenty-two days). — First dressing; wound
nearly healed ; highest temperature since the operation 100-4°.
Applied plaster splint with fenestra opposite wound.
April 1st. — Wound healed ; union pretty firm.
Discharged July 10, 1885 (twenty weeks), with good union;
good position of foot; good motion in ankle joint and with no
perceptible shortening of the limb.
Case V. — Leopold Marks, German, tinsmith, aged forty-
three; healthy.
July 10, 1885. — A heavy slab of marble fell on his left leg
to-day, producing a compound and comminuted fracture at the
junction of the lower and middle third.
11th. — Under irrigation, an incision four inches long over
the crest of the tibia showed the fracture to consist of five frag-
ments. Its general direction was first from above downward
and outward, then from above downward and inward, the two
lines including a large wedge-shaped piece of bone, measuring
three inches in length on its longest side, and including at its
apex nearly the whole of the diameter of the bone. This, to-
gether with two smaller fragments, was found to be so complete-
ly isolated from all vascular supply that its removal from the
wound was rendered necessary ; in fact, the large fragment was
turned upon itself so as to occupy an antero-posterior position
with regard to the long axis of the tibia, while one of its sharp
points had seriously lacerated the deep muscles of the leg and
was lying in dangerously close proximity to the posterior tibial
artery. Deep pockets, filled with clotted blood and reaching
for two or three inches above and below the wound, were ex-
posed and cleansed. The main fragments were then drilled in
two places and brought together with heavy silver wire; the
wound closed and drained through one of the bone punctures; ■
the limb dressed antiseptieally, and put up like the others.
The patient had no symptoms worthy of note. Dressings
changed on the twelfth day, and the wound found healed; tube
removed and limb redressed.
August 1st. — Plaster splint applied. Patient still under
treatment.
Through the courtesy of Dr. L. W. Hubbard, formerly
house surgeon to Bellevue Hospital, I am accorded the
privilege of bringing to the notice of the society the promi-
nent features of one of the most interesting and instructive
cases of this kind which have ever fallen under my obser-
vation.
This case, in which I had the pleasure of assisting Dr.
Hubbard, will be reported in full in the " Xew York Medi-
cal Journal " in connection with my own.*
Case I. — Fracture of the Patella. — Henry Yilner, Hebrew,
peddler, aged twenty-four; feeble health, badly nourished.
June 9, 1883. — Patient was knocked down in the street to-
day and sustained a transverse fracture of the right patella
When admitted to the hospital there was a large effusion of bloo<
into the joint, with great swelling and ecchymosis. The frag-
ments of bone were separated about three inches, and it was im-
possible to approximate them at any time. He was treated with
cold applications, ice to the joint, position, and various forms of
apparatus without benefit until July 12th, when the joint was
opened, under irrigation, by a crucial incision, and thoroughly
cleaned out. The fractured surfaces were then scraped, the
fragments drilled and wired, and the joint drained. The wounc
was then closed with a continuous suture of carbolized catgut,
the limb dressed antiseptieally, and the knee joint immobilized
The operation was followed by some sloughing of the edges ol
the skin-wound and by the formation of a circum-articular ab-
scess ; but all eventually repaired, and the patient was dis-
charged, October 1st (sixteen weeks after the injury), with bony
union of the patella, able to walk well, and with about twenty
degrees of motion in the joint.
* Brief history of case given.
Oct. 31, 1885.] HUBBARD: COMPOUND FRACTURE
OF THE TIBIA TREATED BY WIRING.
479
Patient seen -eighteen months after the injury, with full mo-
tion of the joint, with perfect bony union of fragments, and he
stated that he had walked twenty miles the day before without
inconvenience and without artificial support of any kind.
Case II. — Fracture of the Patella. — James Klein, German
baker, aged forty-five ; healthy.
January 9, 1885. — Fell in the street to-day, striking the
bent right knee on a stone and fracturing the patella trans-
versely. The joint was greatly distended with blood and very
painful. I was unable to determine the exact nature of the
fracture on account of swelling and effusion.
The limb was suspended and treated with cold applications.
February 2d. — Knee still very much swollen, hot, tender,
and painful, and I fear a suppurative inflammation of the joint.
Opened joint, under irrigation, by a crucial incision.
The capsule of the joint and the aponeurotic structures were
all extensively lacerated, with their ragged edges turned into the
cavity of the joint. The patella was fractured transversely
about its middle, with the upper fragment split longitudinally
into two portions, but not entirely separated from each other,
while three smaller fragments were found loose in the joint.
The cavity of the joint was enormously distended with clots,
in which the main fragments were deeply buried.
The joint was thoroughly cleaned, the fragments drilled and
wired iD two places; the capsule and aponeurosis trimmed and
sewed up with fine catgut; the skin-wounds closed separately
in the same way, and the joint drained. Antiseptic dressings
were then applied, and the limb suspended in a wire cradle.
Hth. — First dressing (twelve days); wound healed; no fluid
in the joint; tubes removed and new dressings applied. High-
est temperature since the operation, 100'2°.
28th. — Fragments in good position and apparently united ;
applied plaster splint. Discharged about the middle of March.
April 22d (twelve weeks after injury).- — Can bend knee
to right angle, and union seems to be perfect. Walked ten
miles with cane two days ago.
Case III. — Fracture of the Patella. — J. H., laborer, Ameri-
can, aged thirty-three, healthy.
June 10, 1885. — Six months ago patient was thrown from a
wagon and sustained a transverse fracture of the right patella.
The knee joint is now nearly useless; the fragments are three
inches apart, and apparently held together by a very thin fibrous
band. Joint opened under irrigation; the fractured surfaces
freshened, and the fragments drilled in two places, wired, and
the limb put up like the others. The patient had no constitu-
tional disturbance whatever as a result of the operation. At
the end of ten days the wound was dressed and found healed
throughout; drainage-tubes removed and joint redressed.
29th. — Limb put up in plaster splint.
Patient left hospital about the middle of July, still wearing
splint, but apparently with good bony union of the fragments.
The chief points of interest in these cases are, first, the
facility which the method affords for the removal of blood-
clots, foreign bodies, and torn tissue, thereby leaving a com-
paratively clean wound, which is likely to repair with little,
if any, suppuration or sloughing, provided the operation is
done antiseptically.
Secondly, the ability which it gives the surgeon to effect
a complete and immediate reduction of the fracture, and the
subsequent maintenance of the fragments in perfect apposi-
tion by means of the wire suture — an important indication,
and one which it is impossible to fulfill in many cases by
other means; and the consequent avoidance of such irrita-
tion of surrounding soft tissues as must necessarily occur
when rough fragments of bone are allowed to move more or
less upon each other.
Thirdly, the avoidance of frequent dressing, which al-
ways necessitates the disturbance of the reparative processes
to a greater or lesser extent with each repetition ; the in-
creased probabilities of speedy union when the fragments
are securely put together and held in apposition during the
whole course of the treatment, not to mention the saving of
pain for the patient, and of time and trouble for the sur-
geon.
Fourthly, and perhaps most important of all, the ability
which the method gives to the surgeon to save certain limbs,
the seat of bad forms of compound fracture, which would
otherwise seem to demand primary amputation, or which,
if treated in any other way, might seriously endanger life
from prolonged suppuration, sloughing of soft parts, necro-
sis, osteo-myelitis, septicaimia, pyasmia, etc.
A CASE OF
COMPOUND FRACTURE OF THE TIBIA
TREATED BY WIRING*
By LEPvOY W. HUBBARD, M. D.,
LATE HOUSE SURGEON TO BELLEVUE HOSPITAL.
F. L., aged thirty-six years, native of Germany. Patient
was admitted to the hospital about midnight May 15, 1884, hav-
ing been transferred from another institution in the city. The
following history was obtained : Four days ago he had fallen
through the floor of a new building and sustained a compound
fracture of the left tibia. At the time of his admission to
Bellevue the man was in an active delirium, presenting the
usual symptoms of delirium tremens. As the limb appeared to
be well supported and dressed, it was deemed advisable not to
disturb it before attempting to control the delirium.
May 16th. — Less troublesome to-day, though still delirious.
Temperature somewhat elevated, and pulse rapid and compres-
sible.
During the evening it was discovered that considerable
haemorrhage had taken place, and, as the patient was now quiet,
the dressings were changed. On exposing the leg, the fracture
was found to be very oblique and situated about three inches
above the inner malleolus. Owing to the displacement of the
fragments, the sharp point of the upper piece had again punc-
tured the skin, making an additional wound. The skin for sev-
eral inches around the seat of fracture was dark and had a
sloughy appearance. Several free incisions were made in it,
and drainage-tubes inserted. All hemorrhage had apparently
ceased, and the leg was redressed with a thick antiseptic dress-
ing and supported by side-splints.
17th. — The patient was etherized and examined by Dr.
Stephen Smith, Dr. J. W. Wright, and several of the hospital
staff. On removing the dressing, it was found that venous
hemorrhage had taken place, and a large, soft clot lay be-
tween the dressing and the skin ; that the connective tissue
of the entire limb from the ankle to the knee was extensive-
ly infiltrated with blood, and the leg presented the appear-
ance of the first stage of moist gangrene. Indeed, it seemed
almost hopeless to make tho attempt to save it, and I have no
doubt that a few years ago almost any surgeon of experience
would have advised immediate amputation at the knee joint as
the only probable means of saving the patient's life, Influ-
* Presented, by permission, by Dr. J. Williston Wright with his
paper read before the New York Clinical Society, April 24, 1885.
480
ANDREWS: CONTAGIOUS CONJUNCTIVITIS.
[N. Y. Med. Jock.,
enced, however, by the excellent results previously obtained by
wiring severe compound fractures in several other cases occur-
ring on the division, it was determined to try what conservative
surgery uuder strict antiseptic methods would accomplish. The
seat of the fracture was exposed; the clots of blood surrounding
it were removed ; the lacerated connective tissue, sheaths of mus-
cles, etc., trimmed ; and the fragments brought into apposition
as nearly as possible and held together by a suture of silver
wire passed through holes drilled in the bone near the margins
of the fracture. A free incision was then made on each side of
the leg down to the muscles, extending from the seat of fracture
to just below the knee. All of the clots of blood were removed
by scraping and irrigation. The incision on the inner side was
then closed partly with deep silver wire and partly with super-
ficial catgut sutures, drainage-tubes being placed at various
points. The incision on the outside was left open on account
of tension. During the whole of the operation continuous irri-
gation with a solution of hydrarg. bichlor., 1 to 2,000, was em-
ployed. The wounds were dusted thickly with iodoform, and
the limb was dressed with pads of carbolized gauze and borated
cotton, and supported with side-splints held by turns of a car-
bolized bandage.
The patient rallied well from the operation, and had no more
delirium from that time. The temperature rose the next day
to 102-5°, but after that was never above 101 -750, and by the
fourth day was normal.
19th. — The limb was placed in a posterior wire cuirass and
suspended.
Jane 5th — Nineteen days after the operation. — Dressing
changed for the first time. The incision on the inner side was
nearly healed throughout; the granulations on the other side
were healthy and secreting laudable pus.
The fragments were in very good apposition, and granula-
tions had begun to cover the surface of the bone. The leg was
subsequently dressed every seventh or eighth day, and each time
was found much improved.
July 19th. — A plaster splint applied, and patient allowed to
sit up.
October 1st. — Walking about the ward supporting himself
with a crutch.
December 17th. — Discharged from the hospital with wounds
healed, good union of fracture, able to walk well, and with
only a slight amount of shortening.
130 West Twenty-first Street.
CONTAGIOUS CONJUNCTIVITIS ;
ITS CAUSES, PREVENTION, AND TREATMENT *
Br JOSEPH A. ANDREWS, M. D.,
MEMBER OF THE AMERICAN OPHTHALMOLOGIC AX SOCIETY ; OPHTHALMIC SUR-
GEON TO CHARITY HOSPITAL, NEW YORK, ETC.
( Concluded from page 452.)
Prophylaxis of Ophthalmia Neonati. — Starting from
the proposition that the infection of this disease is derived,
in the first instance, from a pathological vaginal secretion
from the mother, thorough and judicious cleansing of the
diseased vagina should be practiced before the birth of the
child, and, when the child of such an infected mother is
born, its eyes should be washed with a saturated solution
of boric acid, and a two-per-cent. solution of nitrate of sil-
ver be dropped into the conjunctival sac; and the child and
mother should not alone be kept from other children, but
the mother should be told of the contagious character of
her disease and warned against using towels, sponges, or
cloths that have been used on her own person, for wiping
her child.
The eye-trouble begins about the second or third day
after birth, also sooner or later; the sooner, the more in-
tense it will be, generally.
Credo first tried thorough cleansing of the diseased
vagina of the mother before the birth of her child. The
number of cases of eye-trouble was diminished thereby, but
it did not disappear. Then he began to disinfect the eyes
of the children, and the results were more favorable. This
is quite natural, because, if the child is infected at the time
of its birth, no amount of attention bestowed upon the
mother would affect the child so long as it was neglected.
At first Crede proceeded as follows : In all cases of gonor-
rhoea or chronic vaginal catarrh in the hospital, the vagina
was frequently washed with lukewarm water, or a solution
of carbolic acid, or salicylic acid, two per cent. ; near term
this was done every half-hour. The eye-trouble was less
frequent, but it was not stamped out. In 1879 he made
the first trial of prophylactic instillations into the eyes of
the new-born immediately after birth, and used a solution of
borax (1 to 60) without satisfactory results.* Then he tried
a solution of nitrate of silver (1 to 40), which was dropped
into the eyes soon after birth. These instillations were
preceded by careful washing of the eyes with a solution of
salicylic acid (two per cent.). Children thus treated re-
mained free from eye-trouble. From June 1, 1880, all
eyes, without exception, were, immediately after birth, first
washed with plain water and disinfected with a solution of
silver nitrate (two per cent.), a single drop being placed in
each eye ; then the eyes were cooled with pledgets of linen
wet in a solution of salicylic acid (two per cent.). The vagi-
nal douching was, on the contrary, discontinued. Only one
child, on the sixth day, had a mild conjunctivitis of the left
eye, without swelling of the eyelids, and was cured in three
days. It was shown in this case that in the hurry the pro-
phylactic instillations had not been made. Sometimes a
slight hyperemia followed these instillations, and now and
then there was a slightly increased secretion in first twenty-
four hours ; these appearances do not persist after the first
day. Previous to the introduction of this treatment in
Crede's clinic at Leipsic ten per cent, of the children born
there had eye-trouble; since its employment, from June 1,
1880, till March, 1883, the percentage was reduced at once:
1880 (7 months), 211 children, 1 case;
1881 400 " 1 "
1882 418 " 2 cases;
1883 131 " No case.
1,160
The patient in 1880 was not disinfected. The mother, in
one of the two cases which occurred in 1882, had syphilis
and gonorrhoea, and what is of interest to us to remember
in this connection is that, in spite of the instillation of sil-
ver nitrate (two per cent.) immediately after birth, it was
too late. Crede says that the other case (1882) resembled
one of catarrhal conjunctivitis.
* "Archiv f. Gynakol.," 1881, Bd. xvii, p. 62.
Oct. 31, 1885. j
ANDREWS: GONTAOIOUS CONJUNCTIVITIS.
481
Abegg* washed the eyes with pure water immediately
after birth. The result was that among 2,266 births there
were 66 cases of ophthalmia neonatorum, or about three
per cent.
At the suggestion of Alfred Graefe, Olshausen f used a
onc-per-cent. solution of silver nitrate, without previously
washing the eyes, and reduced the percentage of ophthalmia
neonati from 12*5 to 6 per cent. ; but he observes that the
percentage would have been even smaller had the measures
been more exactly practiced from the beginning.
Hecker (Munchen) used a one-per-cent. solution of sil-
ver nitrate as a prophylactic, but he had about as many
cases as before, and Crede's criticism upon these results is
that one per cent, is not sufficiently strong.
In Maternity Hospital, Blackwell's Island, New York,
Dr. Garrigues applied a two-per-cent. solution of silver ni-
trate to the eyes of all the children born during his service
at that institution from October 1, 1882, to March, 1883,
and from October 1, 1883, till March 31, 1884, during
which time 351 children were born, but not a single case of
eye-trouble occurred among those children. Dr. Garrigues
does not state whether any of the mothers were infected or
not. At the same hospital, in Dr. Munde's service, the
house surgeon, Dr. B. Hughes Wells, informs me that be-
tween April 1 and May 15, 1885, 83 children were born,
all of whom were treated with silver nitrate (two-per-cent.
solution), there being not a single case of eye-trouble. In
the six weeks preceding Dr. Munde's service (Dr. Murray's
service) 58 children were born. In this instance a one-per-
cent, solution of silver nitrate was used, and there were more
than 10 or 12 cases of ophthalmia neonati, but none of these
cases led to loss of sight ; only in one case was there ulcera-
tion of the cornea, and in this the latter was not perforated.
Horner \ indorses Crede's treatment with silver as the
most effective. In the discussion on Dr. Horner's paper,
the expediency of employing this treatment in private prac-
tice was questioned. It was said that the eversion of the
lids should not be intrusted to a midwife, because she might
drop the solution on the cornea and damage it. Crede re-
plied that he never everted the lids, because he deemed this
superfluous; he dropped the silver solution (two per cent.)
on the cornea without having seen a single case in which
this cauterized the cornea.
Konigstein tt observed, among 1,092 children in Spath's
clinic for whom no prophylactic measures had been adopt-
ed, blennorrhcea in 4*76 per cent. ; catarrh in 14-5 percent.
He adopted Olshausen's plan of washing the eyes frequently
with a solution of carbolic acid, one per cent. Of those
thus treated, two per cent, had blennorrhcea and six per
cent, catarrh. Finally, of 1,300 children treated according
to Crede's method, one half per cent, had blennorrhcea and
six per cent, catarrh.
Felscnrcich, in the clinics of Carl and Gustav Braun, re-
duced the percentage of blennorrhcea by Crede's treatment
from 3-34 to 1-93 per cent.
* H. Abegg, " Archiv f. Gynakol.," 1881, Bd. xvii, p. 503.
f R. Olshausen, " Centralblatt f. Gynakologie," 1881," No. 2, p. 33.
% " Corrcspondenzblatt der schweizer Aerzte," 1882, No. 1.
* " Wiener med. Presse," 1882, No. 24.
In 1881, Bayer* treated 361 children at the Stuttgart
Lying-in Hospital according to Crede's plan, and there was
not a single instance of eye-trouble; while in 1880, among
354 children born at the same institution, there were 34
cases, and in 1879, among 351 children, there were 51 cases
of ophthalmia neonati, no prophylactic treatment having
been then employed.
At the Royal Lying-in Institute in Dresden, Crede's
treatment was introduced on October 1, 1883. f The in-
stillations were made about a quarter of an hour after birth,
after the child had been washed and its eyes cleansed with
a piece of linen dipped in fresh water. In a few cases, in
the confusion occasioned by many births occurring in quick
succession, the instillations were made somewhat later.
From October 1, 1883, to July 10, 1884, 1,002 live chil-
dren were born. Uncleanliness, intense elytritis, and granu-
lar elytritis were present in numerous instances, and other
influences were also noted which might have contributed to
favor a blennorrhceal infection in the children, but not a sin-
gle case of blennorrhceal conjunctivitis occurred.
Crede's treatment, with its instillations of a two-per-cent.
solution of silver nitrate, and especially the additional appli-
cations for twenty-four hours of a solution of salicylic acid
(two per cent.) on pledgets of linen, involves a strict per-
sonal supervision which must be counted. But the evi-
dence, taken all in all, certainly proves the value of a two-
per-cent. solution of silver nitrate as a prophylactic in oph-
thalmia neonatorum ; yet it should not be used to the exclu-
sion of scrupulous cleanliness.
In order to guard against post-natal infection — which,
as I have said, I believe to be more common than that at
the time of birth — children should be kept in their cots
and not given to the mother (if she is infected) except at
the time of nursing, and then all the precautions respecting
the use of sponges, towels, etc., should be kept in mind.
If it is possible, by the means indicated, to cut down
the percentage of cases of ophthalmia neonati so impres-
sively as the statistics cited above would seem to prove
that we can, it is quite impossible to exaggerate in words
the importance of the gain.
Horner has shown that, among 100 blind asylums of
Germany and Austria, between 33 per cent., or, to be more
exact, between 20 per cent, and 79 per cent, of the blind
children had lost their sight from ophthalmia neonati.
In a statistical report submitted to the Blind Congress
in Paris, in 1879, F. Daumas declared that, of 56,391 eye-
patients treated by himself, 1,178 had become incurably
blind, 108 cases of blindness being due to incurable disease
and 1,070 to curable disease.
In the United States, ophthalmia neonati causes blind-
ness in numbers exceeding 32 per cent, of the cases of pre-
ventable diseases of the eye.
Now, inasmuch as blindness from the disease under con-
sideration occurs mainly among the poor, and is due chiefly
to ignorance regarding its dangerous character and the con-
sequent neglect to apply prompt and effective medical aid,
it behooves the profession to draw general attention, and
* "Centralblatt f. Gynakol.," 1882, p. 515.
f Leopold and Wessel, " Archiv f. Gynakol. ," 1881, Bd. xxiv, p. 89.
482
ANDREWS: CONTAGIOUS CONJUNCTIVITIS.
[N. Y. Med. Jock.,
especially that of midwives, to this very important subject.
Our general dispensaries might substantially aid the dis-
semination of this desired intelligence by having conspicu-
ously printed on the card presented to every female patient
who applies for medical aid the following Instructions
REGARDING NeW-BORN InFANTS :
" If the child's eyes become red and matter begins to
run from them, at any time after birth, take the child at once
to a doctor. The disease is very dangerous, and, if
not treated at once, it may destroy the sight of both
EYES."
Let me now give you an outline picture of purulent
conjunctivitis as it is but too frequently seen at our eye-
infirmaries. The mother takes her child to the infirmary
with the statement that the child's eyes had " run matter"
for some days ; but the eyelids had become so red and
swollen, and the child so restless, that she thought she had
better take it to the hospital. We examine the eyes and
find a large slough of one or both corneas, and the sight of
one or both eyes destroyed. Every eye-surgeon has seen
many such cases. Could a stronger reason be given for the
urgency of sending out words of warning to these unfor-
tunate people ? A mother would not neglect early attention
to her child with this disease if she knew how terrible the
consequences would be of so doing. The next question is,
How shall we treat such cases? To return such a child to
its own home would be to expose the rest of the family to
the disease ; and, again, such patients are brought to us at
the infirmaries three times weekly ; they then return daily to
their homes, where the ignorance of the simplest rudiments
of personal and domestic hygiene which invariably prevails
there must necessarily" neutralize whatever good they may
have received at the hospital ; indeed, patients with this
disease require to be under skilled and constant surveil-
lance ; and, if our eye infirmaries will not receive thess
cases because of the danger of infecting their other patients,
the exigencies of the case are best met by the establishing
of a separate hospital for the treatment of contagious oph-
thalmia.
In Great Britain steps were taken last year in the direc-
tion of making efforts to prevent the terrible consequences
of ophthalmia in the new-born, and it is hoped that the
committee appointed for the same purpose at the last meet-
ing of this Academy will succeed better than our colleagues
across the Atlantic in carrying out the plans they may agree
upon to meet the end in view.
Treatment. — The attendant's hands and nails must be
thoroughly cleansed and his or her eyes protected with
protective spectacles. If one eye only is affected, its fellow
should be sealed with cotton-wool, covered with adhesive
plaster, and over this a solution of rubber should be painted,
so as to exclude any discharge which may run over the
bridge of the nose from the affected eye, and, in the case
of infants, the hands should be secured, in order to keep
them from the eyes. In the case of adults, a far better
protective covering for the healthy eye is one recommended
by Dr. Buller, of Montreal, which consists of a piece of
macintosh, about four inches and a half square, with a
watch-glass (old-fashioned, deep glass) fastened to a hole in
the center through which the patient can see ; the whole is
then fixed by broad pieces of strapping to the nose, fore-
head, and cheek, its lower and outer angle being left open
for ventilation. In case of redness or swelling of the con-
junctiva, this covering must be discontinued and the con-
junctiva painted, as a preventive, with a two-per-cent. solu-
tion of silver nitrate, followed by cold applications.
So long as there are increasing redness and swelling of
the eyelids, together with rising temperature of these parts,
and a watery or sticky, transparent secretion, which shows
that we have to do with a pure inflammation, the treatment
must be anti-inflammatory, directed to the contraction of
the paralytic vessels, and thereby diminish the filtration and
diapedesis ; and the remedy is the same in the case of the
eye as in other parts of the body. The ice-cloths should
be applied, and, according to the height of the local tem-
perature, their use should be more or less vigorous ; but, un-
der all circumstances, the cold applications must be diligently
changed, in order that the action of the cold may be as
nearly as possible equable.* When the local heat is very
great, the cold must be maintained day and night,
When purulent conjunctivitis is fairly established, the
indications for treatment are: 1, to wash away the infective-
material as thoroughly and as early as possible ; 2, to ren-
der the conjunctival surface as nearly as possible aseptic.
It is impossible to exaggerate the importance of securing a
perfect fulfillment of the first of these conditions. If the dis-
ease is seen at the very onset, and the eye cleansed at once, its
course will be less violent than where this is not done. This
washing may be done with a saturated solution of boric acid,
or a two-per-cent. solution of carbolic acid, the latter to_
be weaker as the discharge grows less. The eye must, of
course, be carefully examined for any change in the cornea.
It is not necessary that we should employ our solution in
sufficient strength to be germicidal. The ordinary method
adopted in purulent conjunctivitis of washing the eye with
a so-called antiseptic fluid does not kill the bacteria in the
secretion, but removes the contagious principle as complete-
ly as may be, or so dilutes it that it can do harm only in a
less degree ; and it will be found that the secretion actually
decreases in proportion to the disappearance of the cocci
from it. I think that for this reason the irrigation should
be maintained for several minutes at a time — ten to fifteen
minutes. I would then paint the conjunctival surfaces of
the upper and lower lid with a two-per-cent. solution of
silver nitrate, or even twelve per cent, if the conjunctiva is
much swelled ; and, in case the latter strength is used, wash
afterward with a solution of sodium chloride. The strength
of the silver solution is to be regulated by the succulence and
vascularity of the conjunctiva — the more pronounced these
conditions, the stronger should the solution be. This having
been done, cover the conjunctiva with an antiseptic dressing
consisting of boric acid (six per cent.) or carbolic acid (two per
cent.) and vaseline. The vaseline will be retained much long-
er than a watery solution would be. This dressing will, in a
great measure, have the power (without injury to the cornea)
of arresting the vital activity of the bacteria, of starving them
out, as it were, by so changing the nutritive pabulum re-
quired for their development that they can not appropriate
Oct. 81, 1885. j CORNING: SPINAL ANAESTHESIA AND LOCAL MEDICATION OF THE CORD.
483
it to their use. The irrigation will have to be repeated as
often as may be indicated by the quantity and quality of
the discharge. If there is much swelling of the eyelids,
the outer canthus should be cut. The application of cold
should not be made with ice-bags. Pledgets of linen — to
be burned after use — should be laid on a piece of ice at the
bedside, and this application of cold requires care and a
constant attendant.
In the severe forms of gonorrhoea! conjunctivitis — and
this disease is nearly always very severe — when not seen
very early and treated at once, the cornea runs great risk.
The eyelids are intensely swollen, and when the ocular
conjunctiva is much infiltrated the cornea is in great dan-
ger of suppuration, and the treatment should be directed to
the reduction of the pressure on the eyeball and diminution
of the secretion already formed. The pressure caused by
the chemosis and swollen lids compresses the vessels which
supply the margin of the cornea, causing an insufficient cir-
culation. In order to remove this factor, the outer commis-
sure should be divided to its fullest extent, together with
the canthal ligament. The late Mr. Critchett, of London,
proposed to divide the upper lid vertically to the orbital
margin in severe cases, evert the flap and fix it to the skin
above, and he says the cornea does not suppurate when this
is done. Fuchs* has modified this operation. He divides
the outer commissure to such an extent as to relieve also
the symptoms of pressure. He then puts a suture through
the lower lid and attaches it on the cheek, ectropionizing
it entirely. He detached the suture, in the case he reports,
at the end of the fifth day, and the healing was good. If
the cornea is involved, it requires special attention in addi-
tion to the use of atropine. A thorough removal of the
secretion from the upper cul-de-sac is not possible by the
ordinary means; this may, however, be done by means of
a simple instrument which I have devised for the purpose.
The instrument is an eye-speculum, the arms of which are
hollow and the claw deeper than in the ordinary eye-specu-
lum ; it has a number of perforations for the passage of the
fluid, which is supplied by a fountain syringe. It is inserted
between the lids with great gentleness, and care should be
taken not to injure the cornea with it. The lids should be
gently lifted from the eyeball by means of the speculum,
and the spray of fluid allowed to play upon the upper cul-
de-sac. Even when the lids are extremely painful, it is a
relief to have them gently lifted from the eyeball and the
stream of fluid allowed to play upon the upper conjunctival
cul-de-sac.
Of course the use of this instrument should not be in-
trusted to an ordinary nurse, but the physician can at least
perform the operation twice daily, and keep up the irrigation
for from ten to fifteen minutes. The solution of carbolic
acid in the case of adults, when the inflammation is intense,
may be as strong as three per cent. — to be diluted as the
disease improves ; this is astringent as well as antiseptic.
And the silver I would apply, according to the exigency of
the case, in four-per-cent. or twelvc-per-cent. solutions, and
neutralize with salt and water, and then apply the medi-
cated vaseline to the conjunctiva, and over the lids the iced
* " Centralblatt f. prakt. Augenhcilkunde," 1881, p. 198.
cloths. Iodoform has not met with much favor in this dis-
ease. Quinine in solution has also been used, but it has no
JsTo.l
The instrument shown in Fig. 1 may he used for either eye, the tube with the
water-supply being attached at c, and to the upper branch only in case it is
desired to irrigate the upper cul-de-sac alone. Fig. 2 represents a folding
lid-elevator (of large and small size) designed for the same purpose as the
spring-speculum. The tube of the fountain syringe is attached at b.*
advantage over the carbolic acid. Dr. H. Linds Ferguson
(Dublin) reports cases of gonorrhoeal conjunctivitis in which
he has had good results from the use of finely powdered
boric acid. The bichloride of mercury has no claim to
advantage over the boric acid.
Diphtheritic Conjunctivitis. — Measures of prophy-
laxis based upon bacteriology must lie in the future. We
must be content with the enforcement of general hygienic
laws. Mr. Tweedy f used one-per-cent. solutions of quinine
in this disease, and did not see any serious damage to the
cornea when it was used. Iodoform does not seem to be
of much use in diphtheritic conjunctivitis. Vossius J recom-
mends a four-per-cent. solution of salicylic acid in glycerin.
40 West Twenty-fourth Street, New York.
SPINAL ANAESTHESIA AND LOCAL MEDI-
CATION OE THE CORD.
By J. LEONARD CORNING, M. D.
It is my desire on this occasion to draw attention to a
■procedure in therapy which, so far as I am aware, possesses
the merit of novelty. The arguments which I shall advance
in its favor are twofold in kind : First, I shall cite certain
physiological facts with which the procedure in question
stands in immediate relationship ; and, secondly, I shall
endeavor to record conscientiously the actual phenomena
evoked by the use of the method itself.
To take up the argument in this order, I would remark',
then, that, when a certain quantity of a remedy, say strych-
* These instruments are made by Mr. W. F. Ford, of Messrs. Cas-
well, Hazard & Co.
t London " Lancet," 1882, No. 1.
X " Klin. Monatsbl. f. Augenheilk.," Bd. xix, p. 423.
484 CORNING: SPINAL ANESTHESIA AND LOCAL MEDICATION OF THE CORD. [N. Y. Mm Jouk.,
nine, is thrown under the skin of a frog, certain phenomena
make their appearance which show indubitably that the
functions of the spinal cord are profoundly affected. The
animal is thrown into violent convulsions, and assumes a
rigid attitude, and we have presented the picture of an arti-
ficial tetanus. This is a spectacle of the physiological labo-
ratory, and one with which we are all familiar.
If, now, we remove the posterior arches of three or four
of the vertebra} of the animal, and, seizing the membranous
coverings of the cord, insert the end of a hypodermic needle
so that we are able to inject a small quantity of a solution
of strychnine, we shall find, first, that not only are the con-
vulsive phenomena immediately produced, but, secondly,
that a smaller quantity of the fluid is required to evoke
them than when the drug is placed under the skin at a
point remote from the spinal cord.
It was formerly supposed that this phenomenon was due
to the direct contact of the strychnine with the nervous ele-
ments of the cord, but Harley * has shown that the poison
can act only through the intermediation of the blood-vessels,
since, when the latter are separated from the cord, the solu-
tion remains entirely inert, the convulsions failing to ap-
pear.
From the foregoing considerations, it is clear that, in
order to obtain the most immediate, direct, and powerful
effects upon the cord with a minimum quantity of a medici-
nal substance, it is by no means necessary to bring the sub-
stance into direct contact with the cord ; it is not necessary
to inject the same beneath the membranes, as in the case of
the frog, since the effects are entirely due to the absorption
of the fluid by the minute vessels. On the other hand, in
order to obtain these local effects, it is first necessary to in-
ject the solution in the vicinity of the cord, and, secondly,
to select such a spot as will insure the most direct possible
entry of the fluid into the circulation about the cord. Is
there in man a locality which fulfills these conditions? In-
stead of answering this question at once, I will rather detail
some recent experiments performed by myself, by means of
which, I trust, all doubts on the subject will be effectually
set at rest.
Protocol of Experiments. — Some time since I began
a series of experiments with a view to determining whether
the local medication (anassthetization) of the spinal cord
was within the range of practical achievement. The drug
made use of was the hydrochlorate of cocaine. As the in-
troduction of a hypodermic needle beneath the membranes
of the medulla spinalis is not practicable without removal of
the arches of the vertebras (on account of the danger of
wounding the cord), I decided to inject the anaesthetic be-
tween the spinous processes of the lower dorsal vertebras. I
was led to resort to this expedient from a knowledge of the
fact that in the human subject numerous small veins (venae
spinosas) run down between the spinous processes of the
vertebra?, and, entering the spinal canal, join the more con-
siderable vessels of the plexus spinalis interna. From these
theoretical considerations I reasoned that it was highly
probable that, if the anaesthetic was placed between the
* " A Hand-book of Therapeutics," by Sydney Ringer, M. D., New
York, mo, p. 387.
spinous processes of the vertebras, it (the anassthetic) would
be rapidly absorbed by the minute ramifications of the veins
referred to, and, being transported by the blood to the sub-
stance of the cord, would give rise to anaesthesia of the sen-
sory and perhaps also of the motor tracts of the same. To
be more explicit, I hoped to produce artificially a temporary
condition of things analogous in its physiological conse-
quences to the effects observed in transverse myelitis or
after total section of the cord. I therefore anticipated a
more or less local action of the drug upon the cord. My
hopes in this regard were based somewhat upon the well-
known lethargy of the circulation in the cord, particularly
at its lower portion — a condition of things highly promotive
of the local action of the drug.
Experiment I. — This was performed on a young dog. At
ten o'clock, a. m., I injected twenty minims of a two-per-cent.
solution of the hydrochlorate of cocaine into the space situated
between the spinous processes of two of the inferior dorsal ver-
tebras. Five minutes after the injection there were evidence*
of marked inco-ordination in the posterior extremities ; the dog
threw his hind-legs about aimlessly, holding them far apart,
much after the manner of some ataxic patients. A few minutes
later there was marked evidence of weakness in the hind-legs,
but there were no signs whatever of feebleness in the anterior
extremities. I now tested the condition of sensibility by means
of a powerful faradaic battery, one of the conducting cords of
which was attached to a fine wire brush. When the wire brush
was applied to the hind-legs, there was no reflex action what-
ever on the part of the latter, at least such was the case except
when the most powerful currents were employed. But, on the
other hand, when I applied the wire brush to either of the an-
terior extremities, the limb was drawn away violently, and the
animal set up the most dismal howls. Similar effects were ob-
served on pinching and pricking the limbs.
These phenomena persisted for a considerable length of time,
and traces of inco-ordination were observed two hours after the
injection had been made. After the lapse of about four hours,
however, the dog seemed to have recovered his usual health,
and walked about without difficulty.
During the duration of the experiment nothing of an
abnormal nature was observed in the fore-legs. I infer
from this fact that the action of the anaesthetic was practi-
cally local, being confined, for the most part, to that portion
of the cord situated immediately beneath the point of in-
jection. It is conceivable, however, that, had the quantity
of anaesthetic fluid injected been greater, the anterior limbs
might also have been affected. An absolute localization of
of the anaesthesia is indeed hardly within the range of pos-
sibilities, on account of the numerous blood-vessels. It is
true, nevertheless, as we have seen, that the local action of
the drug is greatly favored, at least so far as the inferior
segment of the cord is concerned, by reason of the lethargy
of the circulation at this point.
Experiment II. — This was performed on a man who had
long been a sufferer from spinal weakness and seminal incon-
tinence, and who for many years had been addicted to mastur-
bation and other forms of sexual abuse. Without entering into
the details of the case, which are devoid of any special interest,
I will proceed at once to give an account of the experimental
observation which constitutes its only claim to attention.
As in the case of the dog previously referred to, I was bent
upon abolishing reflex action and annulling sensory conduction
Oct. 81, 18*5.]
KESSLER: SEASICKNESS AND ITS TREATMENT.
485
in the cord. To this end I injected thirty minims of. a three-
per-cent. solution of the hydrochlorate of cocaine into the
space situated between the spinous processes of the eleventh
ami twelfth dorsal vertebra}. As there was no numbness, ting-
ling, or other evidence of modified sensibility after the lapse of
six or eight minutes, I again injected thirty minims of the solu-
tion at the same spot and in the same manner. About ten
minutes later the patient complained that his legs felt sleepy " ;
and, on making a careful examination with the wire brush, I
found that sensibility was greatly impaired. Currents which
caused lively sensations of pain and reflex contractions in the
upper extremities were disregarded and barely perceived in the
lower limbs. The same was true of the prick of a needle.
Fifteen or twenty minutes later the anesthesia had increased in
intensity, and, although there were some evidences of diffusion
on the part of the anaesthetic, the impairment of sensibility
•was principally limited to the lower extremities, the lumbar
regions, the penis, and the scrotum. About this time I applied
the wire brush to the soles of the feet and to the toes, using
about the maximum strength of a powerful faradaic battery,
without causing either pain or reflex contractions, while a cur-
rent of half the strength evoked intense pain and reflex con-
tractions in the upper limbs. Some time later I fancied that
I could discern some obtuseness of sensibility in the upper
limbs ; but on this point I feel compelled to speak with reserve.
When the patient closed his eyes he experienced some dizzi-
ness while standing, but there was no inco-ordination or motor
impairment discernible in the gait. The power of distinguish-
ing differences in pressure seemed also to be preserved; but I
regret to say that 1 did not test the sensibility to variations of
temperature. The passage of a sound, though usually accom-
panied by considerable pain, remained almost unperceived, and
an urethral electrode caused no inconvenience, even when
strong currents were used. The sensibility of the scrotum and
glans penis was also impaired to a marked degree, as proved
by repeated tests with the electric brush. The pupils were but
slightly dilated.
When the patient left my office, an hour or more after the
injections, sensibility was still impaired to a marked degree,
but otherwise he seemed none the worse for his experience.
The patellar tendon reflexes were, however, abolished.
The therapeutic advantages afforded by such local medi-
cation would seem to be great in a large number of morbid
conditions of the cord. There is, indeed, no reason why
strychnine and other remedies should not be employed in
this local manner as well as cocaine. In strychnine poison-
ing, tetanus, and hydrophobia, it should also render good
service. I will merely add that on the morning succeeding
the injections the patient informed me that he had expe-
rienced tingling sensations and numbness in the lower limbs
until nightfall. There was also dryness of the throat and
mouth, accompanied by mental exhilaration. I could hear
nothing of any cardiac disturbances.
On making an examination with the electric brush, sen-
sibility was found to be normal in the lower limbs, scrotum,
and glans penis. The passage of the sound was, as for-
merly, accompanied by some pain, and the urethral elec-
trode provoked unpleasant sensations, even when mild cur-
rents were employed.
The only constitutional symptoms complained of were
headache and slight vertigo, already referred to. At no
time was there nausea.
Whether the method will ever find an application as a
substitute for etherization in genito-urinary or other branches
of surgery, further experience alone can show. Be the des-
tiny of the observation what it may, it has seemed to me,
on the whole, worth recording.
26 West Forty-seventh Street, October £7, 1885.
SEASICKNESS AND ITS TEEATMEJSTT.
By ADOLPH KESSLER, M. D.,
NEW YORK.
In the " New York Medical Journal " of September 20th
I find a therapeutical note, taken from the " Berlin, klin.
Wochenschrift" and "Lancet," in which Manassein recom-
mends the use of cocaine in seasickness, and speaks of the
gratifying results obtained in several cases. Unaware of
the fact that it had been recommended and used in seasick-
ness, I gave it a pretty extensive trial this summer, merely
prompted by its general physiological and anaesthetic effects,
but with results far from gratifying. It does not act as a
palliative, much less as a curative ; on the contrary, its use
does actual harm. The effect of cocaine upon seasickness,
as a combination of the most varied bodily and mental sen-
sations, is purely negative, except for a decided increase and
aggravation of certain symptoms. The most striking effect
of the medicine is an intense and persistent nausea, which
becomes the more distressing as all efforts, mechanical or
otherwise, of obtaining relief by vomiting prove unavailing.
Now, any one that has ever suffered the pangs of seasick-
ness will agree with me that this very nausea, unrelieved by
vomiting, forms the most distressing and depressing feature
of the mysterious disorder, and that the act of vomiting is
the only efficacious means by which temporary relief is
afforded and comparative physical and mental comfort re-
stored to the sufferer.
The cocaine seems to exercise a paralyzing influence
upon the motor-nerve apparatus of the stomach, thereby
hindering vomition and preventing the display of the only
function which is apt to give any relief, and which nature
itself has beneficently instituted as a vis medicatrix. This*
characteristic and uncomfortable condition is further aggra-
vated by a total loss of appetite and an invincible repug-
nance to food in every form and shape — an inertia of the
digestive organs, in fact, that is very rarely experienced in
ordinary and even severe yet uncomplicated cases of sea-
sickness. But the influence of the drug does not stop here ;
it reaches further yet and extends to the whole length of the
alimentary tract, giving rise to great torpidity of the intes-
tines ; defecation becomes almost impossible without arti.
fil ial measures, and is even then slow, difficult, and painful,
and reacting unfavorably upon the entire system.
However favorably cocaine might affect the nervous
system, intellect, and mind, under ordinary circumstances
when taken on land, I have certainly failed to notice its
brightening and inspiriting effects during the reign of sea-
sickness, except that it sharpened the panes of the latter by
keeping the suffering victims wide awake and unable to find
rest and oblivion in sleep.
The bromides have enjoyed a certain reputation in
the treatment of seasickness since the late and lamented
486
BOOK NOTICES.
[N. Y. Mkl.. Jouk
Dr. Beard first recommended their use, and there can be
no reasonable doubt of their partial efficacy in a large num-
ber of cases.
Of course, it would be an exaggeration to allege for
them the potency of specifics or even uniform efficacy, but
they exercise a palliative and sedative influence, and miti-
gate considerably the grave symptoms of the disorder. And
yet, in the face of this admission, I should feel unwilling to
recommend their use, as the unpleasant after-effects of the
bromide treatment outweigh by far the benefits which it
apparently confers. A great many persons who resort to
the use of the bromides for the purpose of checking sea-
sickness, and who saturate their systems with the salts
almost to the extent of bromism, enjoy a certain kind of
immunity while on the sea, only to discover afterward that
they purchased comparative comfort at a very high cost.
For, contrary to the usual rule of the disorder ceasing im-
mediately after landing, they do not at once recover that
bodily and mental equipoise that constitutes normal health,
but suffer for some time with varied morbid sensations bear-
ing a close resemblance to seasickness, and affecting alike
body, mind, and temperament. This singular condition,
which I experienced myself twice after using the bromides,
and not otherwise, seems to be a direct and positive result
of the medicinal agency employed, and of its physiological
effort to overcome the affection. It appeared almost as if
Nature had resented the check imposed upon her, and, in
throwing it off, had reasserted her power and avenged the
interference with her laws.
If I can thus adduce nothing in favor of cocaine and the
bromides, it might not be amiss to say a good word in be-
half of the hydrate of chloral, which renders excellent ser-
vice in seasickness, without causing or leaving any ill
effects. It does not directly interfere with and check the
disorder, as the two other remedies seem to do, but merely
mitigates and relieves the most distressing symptoms, and
prepares the system gradually in overcoming the further
inroads of the affection without much discomfort. It
does not restrain the act of vomiting whenever this latter
promises to afford relief, but it relieves the painful and con-
vulsive heavings of the stomach, and, after being taken for
some time, it finally stops the vomiting by removing alto-
gether the nauseous feeling which gives rise to this gastric
disturbance. The sensation of nausea being removed, vom-
iting ceases of its own accord. In doses of twenty grains,
administered twice or three times in twenty-four hours,
chloral relieves all the more prominent symptoms of the
disorder, especially nausea, headache, nervous prostration,
and mental wretchedness ; imparts a sound and undisturbed
sleep, which contributes as much, and perhaps more, to
the general improvement than anything else ; and keeps
appetite, digestion, and action of the bowels in a pretty nor-
mal condition. Having crossed the Atlantic more than a
dozen times, and experienced the horrors of seasickness
in all degrees of intensity ; having, furthermore, tried all
modes of treatment, I can recommend but two measures —
moderate doses of chloral whenever the remedy is not con-
tra-indicated, and total abstinence from the use of excitants
and stimulants in the shape of food and drink.
A bland, wholly unirritating diet is best tolerated b
the stomach, and the effect of artificial appetizers is no
only illusory but actually injurious, while the use of spirit
uous liquors considerably aggravates the gastric and cer«
bral symptoms. The reputation of champagne is exag
gerated, and its good effects are solely due to the carboni
acid which it contains, and which proves far more bcneficia
in the simpler vehicle of certain mineral waters.
644 Lexington Avenue.
Jooh Botites.
Micro-organisms and Disease. An Introduction into the Studj
of Specific Micro-organisms. By E. Klein, M. D., F. Pi. 8.
Joint Lecturer on General Anatomy and Physiology in th<
Medical School of St. Bartholomew's Hospital, London
With 108 Engravings. London: Macmillan & Co., 1884
Pp. xii-195. [Price, $1.]
The reader will recognize in this book the series of articlei
which were published in the "Practitioner" for 1884. It is i
modest little volume, but is none the less a thorough and schol
arly exposition of the subject of which it treats. Dr. Klein'i
reputation as a bacteriologist, which has been increased by hit
prominent connection with the Cholera Commission, will ren-
der his book, small as it is, an authority upon the question oi
micro-organisms. He states briefly and clearly those facts whicl
will be most useful to the general reader, avoiding scientific dis-
cussions so far as possible, and confining himself to concise state-
ments of the latest theories. Of the twenty-one chapters, the
first five treat of the methods of bacteria-cultivation and micro-
scopical examination, the next three of bacteria and micrococci,
while the ninth, tenth, and eleventh chapters deal with bacilli.
Vibriones, spirobacteria, yeast and mold, fungi, and actinoray-
ces, have each a separate chapter. Chapters XVII, XVIII, and
XIX treat of the vital phenomena of micro-organisms. The
concluding chapter contains a brief statement of our present
knowledge with regard to germicides. The illustrations are
well executed and assist materially in the understanding of the
text. There are copious references to the literature of the sub-
ject, and a complete index. It is easy to believe from the
amount of research displayed in the little work that it is the
outcome of ten years of careful experiments and investigations,
as is stated in the preface.
A Compend of Organic and Medical Chemistry, including Uri-
nary Analysis and the Examination of Water and Food. By
Henry Leffmanx, M. D., D. D. S., Professor of Chemistry
and Metallurgy in the Pennsylvania College of Dental Sur-
gery, etc. Philadelphia: P. Blakiston, Son, & Co., 1884.
Pp. viii-124. [Price, $1.]
As a quiz compend this handy little volume will be found to
contain most of the information necessary to the medical stu-
dent. The first half of the book treats briefly of organic chem-
istry. There are rather more ponderous formulae than we
should look for in such an elementary work. Animal chemis-
try receives a short notice. The section upon urine is the best
in the book, being concise and practical. We are glad to meet
with a full description of Dr. Squibb's simple quantitative test
for urea. The picric-acid test for sugar is also not forgotten.
A short chapter on water-analysis and one on foods conclude
the compend. The book is neatly bound, and there is an ex-
haustive index.
Oct. 31, 1885.]
LEADING ARTICLES.
487
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SxVTURDAY, OCTOBER 31, 1885.
DI ELECTROLYSIS.
Among the "Therapeutical Notes" which we present this
week, there is one that will undoubtedly awaken the interest,
not to say the curiosity, of many of our readers. We refer
to the brief paragraph which summarizes a communication
lately made to the Paris Academic de medecine by M. Brondel,
on the direct medication of the internal organs by what he
terms "dielcctrolysis," meaning thereby the electrolytic decom-
position of a chemical compound and the forcing of its active
medicinal constituent through the tissues of the body by virtue
of its affinity for one of the poles of a galvanic battery.
Perhaps this is the most notable therapeutical novelty that
has come up since the anaesthetic power of cocaine was an-
nounced. We think it proper to call it a novelty — just as we
felt justified, some months ago, in speaking of rectal anestheti-
zation as a novelty, although something in the same direction
had been done before by Pirogoff and others — although, within
hut a very few days of the date of M. Brondel's communication,
a well-known French author, M. Spillmann, showed that, so
long ago as in 1811, he had published something to the same
purpose, and had referred to the idea as having been entertained
by some others even at an earlier period. M. Spillmann's ex-
periments were performed in 1870, and he published a note in
the "Archives g6nerales de medecine" (1871, vol. ii, p. 490), in
which he said: "It is known that, by causing a galvanic cur-
rent to pass through a solution of iodide of potassium, we cause
the metal to be deposited at the negative pole, and the iodine at
the positive pole. The same thing will take place if a tissue
which is a good conductor is interposed between the two elec-
trodes. It is easy to convince one's self of the truth of these
statements. Beer (' Berl. med. Presse,' x, 1869, 37) and Eulen-
burg (' Berl. klin. Wochenschr.,' vii, 1870, 16) were the first to
dream of the application of these phenomena. In my experi-
ments I 'made use of glass cylinders, traversed at one end by a
platinum wire, and closed at the other with an organic mem-
brane. To avoid every source of error, the cylinders were
scrupulously cleansed after every experiment, the membrane
was changed, and the platinum wire was heated. Experiments
were made by interposing a disc of potato, the thigh of a frog,
a bit of veal two centimetres in thickness, then the forearm, the
thigh, the hand, and the cheek."
M. Spillmann added, in substance : " It seems evident that
iodine may be transported through living tissues from the nega-
tive to the positive pole. This transfer may take place even in
cases where no reaction is found at the positive pole; in its
transit through the tissues the iodine may encounter alkaline
solutions by which it is arrested, and it may also be swept away
in the circulation. If its therapeutical application is really
efficacious, the method of which we have been speaking would
have the advantage of acting directly and most intensely upon
a given diseased part. I believe, nevertheless, that the applica-
tion of electrolysis to the passage of medicinal substances is
subject to many a drawback ; the intensity of the current
necessary to the purpose is generally such that often the patient
can scarcely endure it. Moreover, can not the same results be
arrived at, more slowly perhaps, by the internal administration
of the drug?"
In something like the foregoing words, M. Spillmann calls up
his former expressions in a recent letter to the " Gazette heb-
domadaire de medecine et de chirurgie," and he adds: "These
conclusions, which I formulated in 1871, I would to-day repro-
duce. Less fortunate than Dr. Brondel, I employed electro-
lysis for ganglionic tumors, goitres, articular affections, etc., but,
I must say, without much success. I also tried experiments
with the aid of arsenical salts and salts of mercury. I did not
think that I ought to persist in a course which seemed to me
quite inferior to other well-known methods of introducing
medicaments into the economy."
Certainly, we have here a valid claim of priority, but, alasj
at the same time, a wet blanket thrown over the method. An-
other check to our enthusiasm is encountered in M. Dujardin-
Beaumetz's report to the Academie, to the effect that M. Bar-
det, the well-known electrician, had repeated some of M. Bron-
del's experiments, and always with negative results. But it
may be well to bear in mind M. Spillmann's suggestion as to the
medicinal substance being arrested in its course through the
tissues. At all events, it seems to us that M. Brondel's plan
should not be hastily declared unworthy of further trial.
THE PROPOSED NATIONAL ACADEMY OF MEDICINE.
In this issue we publish a letter from the gentleman whose
plan for a new national medical society we outlined some weeks
since. Our correspondent now gives more definite details, and
corrects some misapprehensions as to the precise scope of his
idea.
There is only one point in regard to which we must utterly
disagree with him, and that is his modest assumption that he
himself is not likely ever to be made a member of such an
august body as he proposes. He still wishes his name not to
be mentioned in connection with the matter, and is even so
careful as to ask not to have any hint given as to the locality
from which he writes. While we accede to his preference in
these particulars, we must express our regret that the weight
of his name is withheld from the support of the undertaking.
We are quite convinced that some such plan as that which
he has worked out will sooner or later be taken up by the pro-
fession. It is evident that such an organization would soon
have weighty matters of business to act upon at its semi-annual
meetings, but, yet, that it wrould be free from any temptation to
such snap action as the American Medical Association took at
its New Orleans meeting. It seems likely, therefore, that, not
only as a scientific body, but also as the body most competent
488
MINOR PARAGRAPHS.
[N. Y. Med. Jolr.,
to enact what little legislation the profession might be in need
of from time to time, it would at once take the leading position
before the world, regardless of what might or might not be
done by the national medical associations now in existence.
MINOR PARAGRAPHS.
DIRECT MEDICATION OF THE SPINAL CORD.
The phenomena which Dr. Corning describes in this number
of the "Journal," as the result of injecting a solution of cocaine
into the tissue between two vertebral spinous processes, seem to
point the way to a new development of the practice of local
medication. The part which, as be suggests, may be taken by
certain veins of considerable size situated in the interspinous
spaces is a matter that is doubtless still to be worked out, but it
will be seen that he lays little stress upon this matter of theory.
The main point is that, should it be shown to be safe, the prac-
tice to which his observations may lead appears likely to offer a
very prompt way of bringing a portion of the organism under
the influence of a drug — one that may prove a precious resource
in certain desperate conditions.
THE SUPPLY BILL AND THE STATE BOARD OF HEALTH.
"While, as we pointed out last week, we can not admit that
the Ways and Means Committee's interpolation of the word "de-
ficiency " in the clause appropriating a sum of money to the
board's use, to enable it to carry out a system of sanitary inspec-
tion, justified the Governor's veto — both because the context
makes it apparent that the word was not intended to convey
the idea that the board had asked for the means of making good
a deficiency in the accounts, and because two other items for
the board's benefit were likewise vetoed (one of them appropri-
ating the small sum of five hundred dollars to cover various
minor disbursements— among other things, for laboratory appli-
ances)— we must, nevertheless, give it as our judgment that the
committee was not at all warranted in submitting to the Gov-
ernor a bill so loosely drawn. Surely, a " committee on style "
would be in order at Albany.
AN ANTI-VACCINATION AGITATION.
Those unhappy individuals who from time to time make a
public display of their horror at the practice of vaccination
lately held a meeting in New York, at which they demonstrated
anew their utter lack of appreciation of facts. There is little
danger of their making any impression on the community; but
why were they so cruel as to time their meeting so as to pre-
clude the attendance of those of their brother "cranks" who
may have felt more urgently impelled to take part in the meet-
ing of believers in " faith cures " held in Buffalo ?
INSANITY AMONG FEMALE PHYSICIANS.
" Lyon medical " makes the remarkable statement that sta-
tistics show the disastrous effects of medical study on the intel-
lectual faculties of woman. In the year 1881, it appears from
the census, there were twenty-five women practicing medicine
in England, and our contemporary thinks that the number has
undoubtedly increased since that time. From 1880 to 1884,
eight had been placed in lunatic asylums, and at the close of
last year three were under treatment.
NEWS ITEMS, ETC.
The Health of Foreign Cities.— We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office since
the date of the last bulletin, October 7th : Montreal, Canada)
—For the week ending October 21st: The epidemic of small-
pox has spread rapidly during the week. The deaths reported
in the city were 394 and in the adjacent municipalities 96, as
compared with 262 and 70, respectively, in the week ending
October 13th ; 2,454 deaths from the disease have been reported
in Montreal and vicinity from the beginning of the epidemic to
October 21st, inclusive. Toronto, Ontario. — For the week end-
ing October 17th : No further reports of small pox. Havana,
Cuba.— Yor the week ending October 15th : 14 cases of yellow
fever and 6 deaths. Cardenas, Cuba.— For the week ending
October 17th: Free from epidemic diseases. Matanzas, Cuba.
— For the week ending October 14th : The same. Nassau,
N. P.— For the week ending October 3d: The same. San Do-
mingo.— For the week ending September 16th: The same.
La Guayra, Venezuela. — For the week .ending October 3d :
Yellow fever still prevalent and fatal in Caracas; a few cases
of suspicious character have occurred in La Guayra. Parit,
France. — For the week ending October 10th: 3 deaths from
small-pox. Rheims, France. — For the week ending October
3d: 4 cases of small-pox and 1 death. Antwerp, Belgium. — For
the week ending October 10th: 3 cases of small-pox. Copen-
hagen, Denmark. — For the month of August: 11 deaths from
small-pox. Barcelona, Spain. — September 21st to 30th: 392
cases of cholera and 137 deaths. During the month of Sep-
tember 1,440 cases and 609 deaths were reported. The epidemic
is abating generally, although an increase in the number of cases
and deaths is observed at times, the victims being chiefly those
who left the city on the appearance of the disease and have re-
cently returned. Cadiz, Spain. — For the week ending October
3d : 73 deaths from cholera. Valencia, Sjmin. — For the week
ending October 3d: 2 cases of cholera and 1 death. Venice,
Italy. — For the week ending September 26th : 5 deaths from
small-pox. Trieste, Austria. — For the week ending October
3d: 8 cases of small-pox and 4 deaths. Prague, Bohemia. —
For the week ending October 8th : 2 deaths from small-pox.
Calcutta, India. — For the week ending September 12th : 4
deaths from cholera. Shanghai, China. — August 21st to Sep-
tember 4th : 8 cases of cholera and 5 deaths. The disease is
said to be more prevalent among the Chinese than for manj
years. Toulon, France. — September 5th to 10th : 57 cases ol
cholera and 23 deaths. The following is the number of cases
and deaths from cholera in Italy from September 17th to 23d,
inclusive : 1,323 cases and 820 deaths. In Spain, from March
4th to September 23d, there were 264,629 cases of cholera and
97,865 deaths.
.Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending October 27, 1885 :
Week ending Oct. 20.
Week ending Oct. 27.
DISEASES.
Cases.
Deaths.
Cases.
Deaths.
3
1
0
0
33
12
37
8
21
3
24
3 i
Cerebrospinal meningitis. . . .
4
4
0
1
6
0
7
1
53
22
46
25
1
1
1
0
The Cholera in Spain.— The United States consul at San-
tander reports to the Secretary of State, Washington, under date
September 19th, that the epidemic is decreasing, and hopes are
entertained that the disease will soon entirely disappear. The
consul at Algiers telegraphs, October 24th, "public health is
doubtful ; ships will leave with foul bills of health."
Oct. 31, 18515.]
MINOR PARAGRAPHS.
489
Yellow Fever at Ship Island.— Three cases of yellow fever
have been reported, at the office of the supervising Surgeon-
General of the United States Marine- Hospital Service, as having
arrived on a vessel recently from Havana.
The Medical Society of the County of New York.— At
the meeting of October 26th officers were elected as follows :
President, Dr. Daniel Lewis ; Vice-President, Dr. Laurence
Johnson; Secretary, Dr. Wesley M. Carpenter; Assistant Secre-
tary, Dr. Charles H. Avery ; Treasurer, Dr. Orlando B. Doug-
las; Censors, Dr. F. R. S. Drake, Dr. H. T. Peirce, Dr. W. E.
Bullard, Dr. W. O. Moore, and Dr. F. M. Weld.
At the Same meeting the following amendments to the by-laws
Were passed: The first one, offered by Dr. Jacobi and passed
unanimously, reads " That the Comitia Minora be directed to
recommend no applicant for admission to membership unless he
be a graduate from a medical college in good standing, or a licen-
tiate of a regular unsectarian State or county medical society of
this or any other State ; or, if his diploma or license be of sec-
tarian character, unless the applicant declare in writing his or
her abnegation of sectarian principles and practice." The sec-
ond provided that the annual dues should be the sum voted at
each annual meeting, but not exceeding five dollars. The third
provided that the annual dues should be payable in advance
after the annual meeting, and that they should be remitted, for
the year in which they joined, to those who joined the society
in the months of September and October. The first of the two
following paragraphs was passed, by a small majority, after much
discussion ; the second was lost :
1. "If any member shall fail to pay the yearly dues within thirty
days after the fourth Monday in November, when the same shall become
payable, it shall be the duty of the treasurer to serve, in the manner in
which notices in suits are required to be served on attorneys, upon each
member so in default, a copy of this by-law and a notice to the effect
that unless such dues are paid within fourteen days thereafter his name
and the amount due by him will be reported to the society at its next
succeeding stated meeting, and entered upou the minutes ; and, if they
are not so paid, the treasurer shall report the same accordingly. At
the next stated meeting of the Comitia Minora after the date of such
report, the Comitia may, by order, without further notice, strike from
the roll the name of any member continuing in default, and he shall
thereupon cease to be a member of the society, provided that, upon his
written application explaining such default, and the payment of all dues
to the date thereof, or provided that the Comitia unanimously remits
the arrears, the Comitia shall have power to remit the penalty of this
by-law."
2. " It shall be the duty of the treasurer to take a similar proceed-
ing in the case of any member who shall have had credit for a part of
his initiation fee, and also any candidate who has no credit for initia-
tion fee, and who shall fail to pay the same after demand thereof made
within fourteen days after the expiration of the three months allowed
by the by-laws (Chapter XII, Article 4), for completion of membership ;
and the terms of the foregoing by-law shall apply to the last-mentioned
cases in all respects."
Tho proposed amendment to Chapter IV, Article 4 — which
read, '• It shall be the duty of the secretary to prepare annually,
and send to each member of the society, a register containing
the names, addresses, and office hours of the active members of
the society, the register to be prepared at such time and in
such manner as the Comitia Minora shall direct" — called forth
remarks by Dr. Jacobi, who thought it would be better to pro-
vide for such a register by special action from year to year than
in a by-law. It would be desirable, he added, if the society
could prepare an official register for the entire State and adjoin-
ing counties, to take the place of the faulty register issued by
the Medico-Historical Society. Dr. Loomis indorsed the re-
marks made by Dr. Jacobi regarding the desirability of having
an impartial official register of the State and adjoining coun-
ties, and moved an amendinent providing for the same to be
issued by the county society. On motion, the whole matter was
referred to the Comitia Minora with power. The annual dues
for the coming year were fixed at three dollars.
The Discontinuance of the Michigan State Inspection
of Travelers is announced in a circular, dated October 21st,
addressed to the inspectors, and signed by the secretary of the
State Board of Health, Dr. Henry B. Baker. The circular reads
as follows :
" Gentlemen:" The State Health-Inspection Service, established by
this board under Act No. 230, "Laws of Michigan, 1885, will cease imme-
diately, in accordance with a letter this day received from Governor
Alger, in which he says : ' Of course, however, the State Board will not
discharge these officials until the [United States] Government takes the
matter up.' By request of the Governor, I have informed Dr. H. W.
Sawtelle, U. S. Marine-Hospital Service, Detroit, Mich., that ' this State
will take no further action in the matter.' I understand that the rea-
son for this is that the Governor considers that the ' Regulations for the
Maintenance of Quarantine Inspections on the Northern Frontier of the
United States,' issued by the Treasury Department of the United States
(Department No. 153), and approved by the President of the United
States, is applicable in Michigan as well as in other States, and that the
United States Government should maintain the inspection in Michigan
as well as in other States. In closing, permit me to thank you for your
efficiency. During your service no. small-pox has entered Michigan, so
far as known ; but it has been reported to have been conveyed from
Montreal, by person or otherwise, to Maine, New Hampshire, Vermont,
Massachusetts, Rhode Island, New York, Pennsylvania, Illinois, and
Wisconsin. The most exposed of any State, Michigan has so far es-
caped."
The rules under which the inspectors acted were as follows :
" 1. All travelers and immigrants coming into Michigan from Ontario
shall be subject to inspection by an officer appointed by the Michigan
State Board of Health. 2. All baggage, household goods, and other
effects, belonging to people moving into the United States or to sus-
pected travelers, must be disinfected before entering the country. 3.
All immigrants and suspected travelers who do not present proper evi-
dence of recent vaccination or other immunity from small-pox must be
vaccinated before entering the State. 4. After October 15, 1885, no
passenger-car coming from Montreal or other infected district shall be
allowed to enter the State without being properly disinfected. 5. Freight
and cars from Montreal or other place liable to be infected, consigned
to any place in Michigan, must be thoroughly disinfected before being
allowed to proceed. (See Rules 19, 22, and 31, Rules of this Board,
under Act No. 230, Laws of 1885.) Inspectors are expected to notify
health officers of places outside of Michigan to which are consigned
freight-cars from suspected places, if they are not disinfected because
not consigned to this State."
The inspectors at Port Huron were Hiram R. Mills, M. D.,
M. Northup, M. D., and Mortimer Willson, M. D. Those at De-
troit were J. J. Mulheron, M. D., Wm. Fitz-IIngh Edwards, M.
D., F. W. Owen, M. D., A. B. Chapin, M. D., and F. D. Heisordt,
M.D.
The Army Medical Corps. — We learn that a board is now
sitting in New York for the examination of candidates for ap-
pointment on the medical staff. We have before published the
circular usually issued to applicants, and we would now call the
attention of candidates to the following paragraphs contained
in the circular:
"III. Oral examinations on subjects of preliminary education, gen-
eral literature, and general science. The board will satisfy itself by an
actual examination that the candidate possesses a thorough knowledge
of the branches taught in the common schools, especially of English
grammar, arithmetic, and history and geography of the United States.
490
MINOR PARAGRAPHS.
fN. Y. Mbd. JonH.,
Any candidate found deficient in these branches will not he examined
further."
" IV. Written examination on anatomy, physiology, surgery, prac-
tice of medicine and general pathology, obstetrics, and diseases of wo-
men and children. Oral examination on these subjects, and also on
medical jurisprudence, materia medica, therapeutics, pharmacy, toxi-
cology, and hygiene. Few candidates pay the attention to hygiene
which it deserves ; it is always made a subject of this examination and
will be considered a vital one in the examination for promotion after
the expiration of five years' service."
The Medical Society of the District of Columbia.— At a
meeting held on Wednesday, the 28th inst., Dr. Joseph Taber
Johnson reported a successful case of hysterectomy for tumor,
the character of which will be determined by the microscopical
committee of the society.
A New Medical College in Washington Territory.— The
medical department of the Territorial University, at Seattle,
was lately organized. The faculty consists of Dr. T. T. Minor
(medicine), Dr. R. Willard (obstetrics and diseases of women
and children), Dr. E. L. Smith (surgery), Mr. J. Baker (chemis-
try), Dr. G. A. Weed (physiology and hygiene), Dr. C. II. Mer-
rick (materia medica and therapeutics), Dr. L. R. Dawson (anat-
omy and histology), Dr. J. W. Waughop (psychological medi-
cine), Dr. J. 0. Sundberg (ophthalmology, otology, and laryn-
gology), and Dr. J. S. M. Smart (adjunct in clinical surgery and
genito-urinary diseases).
The German Faculties. — According to the " Progres nodi-
cal," Dr. Werth succeeds Professor Litzmann in the chair of
obstetrics at Kiel, and Dr. Ebner has been made a Privat-Docent
at Prague.
Obituary Notes. — The death of Dr. Hewitt 0. Fessenden,
of Eastport, Me., took place on Thursday, October 22d, at the
age of sixty-six. He was graduated from the Medical School of
Maine, and had resided in Eastport for about thirty years.
Army Intelligence.— Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from October 18 to October 24, 1885 :
McPaelin, T. A., Colonel and Surgeon. Directed to await fur-
ther orders in New York city. Letter from A. G. 0., Oc-
tober 19, 1885.
Yollum, E. P., Lieutenant-Colonel and Surgeon. Assigned to
duty as attending surgeon, Headquarters Department of the
Platte, Omaha, Neb., relieving Assistant Surgeon William
C. Shannon. S. O. 103, Department of the Platte, October
15, 1885.
Heger, Anthony, Major and Surgeon. Directed, in addition to
his present duties as member of Army Medical Examining
Board, now in session in New York city, to perform the du-
ties of attending surgeon in that city. S. O. 240, A. G. O.,
October 19, 1885.
Baily, Joseph C, Major and Surgeon. Granted leave of ab-
sence for twenty days. S. O. 225, Department of the East,
October 19, 1885.
Marine-Hospital Service. — Official List of Changes of
Stations and Duties of Medical Officers of the United States
Marine- Hospital Service, for the two weeks ended October 2Jf,
1885.
Long, W. II., Surgeon. To proceed to Detroit, Mich., and as-
sume charge of the service. October 23, 1885.
Austin, II. W., Surgeon. To proceed to Albany, N. Y., on
special duty. October 14, 1885.
Williams, L. L., Assistant Surgeon. Relieved from duty at '
Norfolk, Va. ; to proceed to Washington, D. O, for tem-
porary duty. October 20, 1885.
Society Meetings for the Coming Week :
Monday, November 2d: New York Academy of Sciences (Sec-
tion in Biology); Medico-Chirurgical Society of German
Physicians; Morrisania Medical Society (private); Brooklyn
Anatomical and Surgical Society (private); Utica, N. Y.,
Medical Library Association ; Boston Society for Medical
Observation ; St. Albans, Vt., Medical Association ; Provi-
dence, R. I., Medical Association; Hartford, Conn., City
Medical Association ; Chicago Medical Society.
Tuesday, November 3d: New York Obstetrical Society (pri-
vate) ; New York Neurological Society ; Elmira, N. Y.,
Academy of Medicine; Buffalo, N. Y., Medical and Surgical
Association; Ogdensburg, N. Y., Medical Association; Hud-
son County, N. J., Medical Society ; Androscoggin County,
Me., Medical Association (Lewiston) ; Hampden, Mass., Dis-
trict Medical Society (Springfield).
Wednesday, November l^th: Medical Society of the County of
Richmond, N. Y. (Stapleton); Penobscot County, Me., Medi-
cal Society (Bangor).
Thursday, November 5th: New York Academy of Medicine;
Society of Physicians of the Village of Canandaigua, N. Y. ;
Medical Society of the County of Orleans, N. Y. (annual —
Albion) ; Boston Medico-Psychological Association ; Obstet-
rical Society of Philadelphia.
Friday, November 6th : Practitioners' Society of New York
(private).
Saturday, November 7th: Clinical Society of the New York
Post-Graduate Medical School and Hospital; Manhattan
Medical and Surgical Society (private) ; Miller's River, Mass.,
Medical Society.
OBITUARY NOTES.
Professor Samuel G. Armor, of Brooklyn.— We regret ex-
ceedingly to be called upon to record the death of Dr. Armor,
which took place on Tuesday, the 27th inst., in consequence, it
is understood, of an attack of pneumonia.
Dr. Armor was born in Washington County, Pennsylvania,
January 29, 1818. His parents, who were of Scotch-Irish stock,
removed to Ohio when he was a mere child, and his training
was therefore almost wholly in the West, Ohio being considered
in those days a part of the far West. He took his medical de-
gree in 1844, at the Missouri Medical College, in St. Louis. His
attainments and his capability as a teacher were speedily and
widely recognized, and for varying periods he was a member of
the faculties of Iowa University, Cleveland University, the Medi-
cal College of Ohio, the Missouri Medical College, and the Uni-
versity of Michigan. Finally, in 1866, he was made professor
of therapeutics, materia medica, and general pathology in the
Long Island College Hospital, and the following year lie became
professor of the practice of medicine and of clinical medicine in
the same institution, a position which he held up to the time of
his death. He was also one of the visiting physicians to the
hospital, a consulting physician to St. John's Hospital, and a
member of the Medical Society of the County of Kings.
Dr. Armor was a painstaking and successful practitioner and
an excellent lecturer. He often took part in the discussions at
meetings of medical societies, and he usually preferred to write
out his remarks for publication, rather than to trust to the re-
porters. The esteem in which he was held was Dot confined to
the city in which he lived; far beyond the limits of Brooklyn
he was recognized as one of the foremost of American physi-
I cians. He was possessed of a cordial, hearty manner which
Oct. 31, 1885.]
LETTERS TO
THE EDITOR.
491
won for him friends among all with whom he came in contact.
His wiry physique gave promise of a long life, and the news of
his death will therefore he all the more shocking to those who
knew him.
f ftters to tbe (SBDitor.
THE PROPOSED NEW NATIONAL MEDICAL SOCIETY.
October SJf, 1885.
To the Editor of the New York Medical Journal:
Sir : I am well satisfied to see by the Journal received to-
day that my suggestion of last summer, relative to a National
Academy of Medicine, has justified itself in the amount of atten-
tion it has attracted. It is particularly encouraging to he able
to infer, from the variety of the views expressed by other jour-
nals and by your correspondents, that the main proposition —
'the present need of an authoritatively representative medical
body in this country — is generally accepted and seriously con-
sidered by writers of widely differing opinions as to how the
need is to be met. The project, if finally successful, must needs
be such as is satisfactory to the profession at large, and can not
be wisely formulated until every important criticism likely to
be offered has been expressed and freely discussed.
When I offered you my suggestion I had in mind as an ex-
ample the American Academy of Sciences. This body is, as
you are aware, a close corporation, limited in number, whose
membership is for life. Admission to its ranks is looked for-
ward to by aspiring students of science as the crowning reward
of their lives, and the visible and public evidence of their suc-
cess. It is recognized by the national Government, to which it
is the official and legal adviser as to all questions of scientific
interest. It is not intended to, and does not in fact, occupy
any part of the field of local or general scientific associations.
And, although its annual elections rarely occur without causing
bitterness and heart-burnings, often more or less just, because
of its failure to choose men who have deserved the honor, this
very fact is an evidence that its plan is successful in practice,
since, if the honor were not earnestly desired, there would be
little disappointment. And although, as has always been true
likewise of the French Academy, any one can point to great
names outside of the Academy with surprise that they are not
upon its rolls, it is equally true that very few get in who ought
to be out.
Very much such a body seems to me to he what is needed
by the medical profession of the United States — not to take the
place of the American Medical Association, or of any other
geographically representative body which may hereafter be
created, but to occupy a place of its own, the vacancy of which
isjust at this time sadly apparent to us all.
There is no scientific virtue in localities, nor can maturity
of judgment or perfection of culture be mapped out by State
lines. A true representation of the medical science of a country
can only be expressed by the association of representative men
— that is, of men who represent the high calling they have
chosen, and not the particular section of the country in which
they happen to reside. Who, for instance, would dare to main-
tain that such men as Austin Flint, Sr., or John C. Dalton, were
representatives of New York city in any such broad and true
sense as their names were household words in the mouth of
every student of medicine in the whole extent of the country?
To limit the discussion, should it continue, to the proposi-
tion which I have in view, I will briefly restate it. I propose:
1. That there be organized a body of one hundred eminent
medical practitioners, to be called the National Academy of
Medicine.
2. That the Academy seek a charter from Congress, recog-
nizing it as the official adviser of the Government, to which
may be referred any question relating to preventive or practical
medicine or the public health which may arise.
3. That membership in the Academy be for life, and that
vacancies occurring therein be filled by the vote of its own
members.
4. That its purposes be, a, the consideration of questions
and prosecution of inquiries referred to it by the national Gov-
ernment ; 5, the discussion and investigation of questions and
inquiries of general importance to medfcal science ; c, the con-
sideration of questions referred to it by local or general medical
societies.
5. That its meetings be two in each year: the annual (busi-
ness) meeting, to be held at Washington, D. C. ; the semi-annual
(scientific) meeting, to be held in such place, variable from year
to year, as may be determined by vote of its members.
As to the best way of starting such an academy my inex-
perience is somewhat at fault, and you will need the counsel of
wiser and more practiced heads. I will, however, suggest the
following as preliminary steps :
Let an informal meeting be called of a very few of those best
and most widely known as teachers in medical science and prac-
tice. You will not have to look far to find half a dozen names
which are on the backs of well-thumbed text-books in every
medical library in the United States. Let these gentlemen draw
up a circular, stating the general purpose of their action, and
send the same to a few of the most widely known medical men in
every part of the country where truly representative men are
to be found. Let the circular request the gentlemen to whom
it is addressed to call meetings in their several localities to dis-
cuss the subject and to suggest modes of preliminary action —
whether, for instance, delegates should be chosen (who should
in no case be themselves candidates for membership) to a gen-
eral meeting for the election of the first fifty of the Academy;
or a plan for original representation should be drafted, appor-
tioning membership in proportion to the number and standing
of the medical schools in a district, according to which local
elections should be held for the selection of the first fifty mem-
bers. When fifty members shall have been chosen, let the
Academy organize, and take its own deliberate time (the longer
the better) for filling its number to the limit of one hundred.
The conditions for membership should not, in my opinion,
be established until after the organization of the Academy ; but
I earnestly hope that the doors will be thrown open as widely
as possible, exacting allegiance to no code or system, and ex-
cluding no class of so-called " specialists," in which material fit
for the purposes of the Academy may be reasonably looked for.
Thus, although perhaps collecting its nucleus, for simplicity's
sake, from districts bounded geographically, the Academy will
be freed from local influences as soon as it is organized, and may
fill up its ranks with due deliberation with those whom it re-
gards as most worthy wherever it may find them.
The greatest difficulties seem to me to lie in the first forma-
tion of the Academy, and I am inclined to think that, consider-
ing the inborn bent of our countrymen toward political methods
even in scientific matters, it will be well that as much as pos-
sible of the preliminary work bo undertaken as a labor of love
by those who, like your correspondent, have no hope of becom-
ing members of the Academy themselves.
I am, sir,
The Correspondent mentioned in toi r
Issue of September 12 th.
492
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
THE CANADIAN EPIDEMIC AND THE STATE BOARD OF
HEALTH.
Albany, October 14, 18S5.
To the Editor of the New York Medical Journal :
Sir : I believe that few of the public or of the profession
know either the limitations of the active powers of the State
Board of Health, or the measures which it has been able to adopt
to prevent the invasion of small-pox from Canada.
Although the board has nominally " cogDizance of the inter-
ests of life and health throughout the State," and is verbally
empowered to " from time to time engage suitable persons to
render sanitary service," the very Act conferring these powers
and duties stipulates that " no more than five thousand dollars
in any one year shall be expended for such special sanitary ser-
vice." Forasmuch as several acts were passed by the last Legis-
lature calling on the State Board to supervise or prepare plans
for public works involving special skill in sanitary engineering,
the larger part of this limited sum is necessarily devoted to such
purposes, and it has been beyond the power, though within the
wish, of the board to engage competent inspectors at all the
points of entry from Canada.
But, in partial compensation for this'involuntary inefficiency
of the central board, the new Public Health Act, passed last
winter, makes it the duty of every local board of health
" To guard against the introduction of contagious and infectious
disease by the'' exercise of proper and vigilant medical inspection and
control of all persons and things arriving in such city, village, or town
from infected places, or which, for any cause, are liable to communicate
contagion ; to require the isolation of all persons and things infected
with or exposed to contagious or infectious diseases, and to provide
suitable places for the reception of the same ; to prohibit and prevent
all intercourse and communication with or use of infected premises,
places, and things ; and to require and, if necessary, to provide the
means for the thorough purification and cleansing of the same before
general intercourse therewith, or use thereof, shall be allowed. And it
shall be the duty of every such board of health to report to the State
Board of Health promptly facts which relate to infectious and epidemic
diseases, and every case of small- pox or varioloid occurring within its
jurisdiction ; and to provide at stated intervals a suitable supply of vac-
cine virus of a quality or from a source approved by the State Board of
Health ; and, during the existence of an actual epidemic of small-pox,
said local board of health shall obtain fresh supplies of said virus at
intervals not exceeding one week, and shall at all times provide thorough
and safe vaccination for all persons within its jurisdiction who may need
the same."
These measures are to be taken at the expense of the several
localities, and, consequently, in a community of frugal-minded
taxpayers, are not likely to be as thoroughly carried out as
might be desired. To maintain a constant guard at places where
trains are frequently arriving; to examine luggage and freight;
to provide vaccine enough for all unprotected persons ; to dis-
infect suspected articles; to provide a " quarantine of observa-
tion " — all these require an outlay of money, which, in a rural
district, is reluctantly given. Nevertheless, to compel the exe-
cution of the act, it is decreed to be a misdemeanor on the part
of any local board to violate " any lawful instruction of the
State Board of Health."
Acting upon the authority thus given, as soon as small-pox
was known to have assumed epidemic proportions in Montreal,
early in June, a circular was sent to every local board of health
on the frontier and along the main lines of travel, directing
them to exercise watchfulness for the exclusion of infected per-
sons or things, and to secure thorough vaccination, especially of
school-children and persons employed about railway stations,
boat landings, and other points of travel or traffic. Thanks to
the energy of most of the local health officers, these precau-
tions were promptly adopted, and in nearly alt the exposed
localities along our extensive border vaccination has been ac-
tively in progress, and the few cases which have been imported
into the State have been effectively isolated without any spread
of the disease. Continual correspondence, by circulars and let-
ters, has been maintained with several hundred local boards,
and every means short of pecuniary assistance that human
effort could compass has been used to insure the protection of
the State; with what success thus far is .shown by the fact
that, while small -pox was raging uncontrolled for months
almost at our doors, not half a dozen cases crossed our line, and
these had no extension. Now that the Canadian authorities
are awakened to more decisive action, I feel even less anxiety
than before popular apprehension was aroused, and greater
confidence in the efficiency of the local boards which have
already served their apprenticeship under the most disadvan-
tageous circumstances. ,
The "epidemic fund" appropriated by Congress last year
is under the control of the Treasury Department, and its finan-
cial aid is given, through the Marine-Hospital Service, only at
the request of the Governors of States, addressed to the Secre-
tary of the Treasury, boards of health having no direct voice
in the matter. The Governor of New York has made official
application for aid from this source, and means will ere long
be provided for the inspection of trains before they reach the
frontier; though even then the number of high-roads crossing
our land boundary-line and the multitude of smaller places of
debarkation along our lake and river shores will still be ave-
nues of possible invasion which it would require almost an army
to guard, and our chief reliance must be in the preventive effi-
cacy of vaccination.
I am, sir, yours faithfully,
Alfred Ludlow Carroll, M. D.
J^roteerjhigs of Sorutus.
NEW YORK SURGICAL SOCIETY.
Meeting of October 13, 1885.
The President, Dr. R. F. Weir, in the Chair.
Hematoma of the Thigh. — Dr. H. B. Sands presented a
specimen obtained from the body of a man who died in June
last in St. Luke's Hospital. The interest of the case lay in dis-
covering, if possible, the seat of the lesion for which an opera-
tion was performed in the month of June, 1883. The case had
been fully reported in the " Archives of Medicine " for Decem-
ber, 1884.
A man, fifty-one years of age, had suddenly developed in
the left thigh a swelling of very large size. At first this was
thought to be an aneurysm, but it lacked many of the features
of an aneurysm, and Dr. Sands diagnosticated a haamatonia
communicating with a vein. At the time of the operation
seven pints of blood, by measurement, were evacuated from
the tumor, and it was estimated that a pint of blood was lost;
in other words, the tumor contained a gallon of blood. He
found a large opening leading from the sac into what seemed
to be one of the profunda veins, and tied the vessel in question
above and below the bleeding point. The man recovered and
regained the use of his limb. Two years later he died in St.
Luke's Hospital of visceral diseases implicating chiefly the liver
and kidneys. At the autopsy a segment of the affected limb
was removed and submitted for examination to Dr. Hall, who
had made the following report :
Oct. 31, 1885.]
About the middle third or fourth of the left femur, with an abnor-
mally developed linea aspera, forming a sharp ridge where the perforat-
ing arteries pass through. Attached to the femur are a part of the
vastus interims, and the adductores longus, brevis, and magnus. Left
in position are part of the rectus femoris and sartorius, the superficial
and deep femoral arteries and veins, the anterior crural nerve, and
posteriorly the great sciatic nerve. Anteriorly the skin and superficial
fascia have been stripped off in great part. At the inner side of the
anterior surface of the specimen, above the vastus internus, a portion
of integument has been left, containing a longitudinal cicatrix about
three inches in length. The long saphenous vein has been dissected
out and cut off above, but remains attached below. It contains a
thrombus throughout its course. The fascia lata has been divided, and
the muscles have been separated so as to expose the superficial femoral
artery and vein throughout. They are pervious and apparently rather
larger than usual, but not atheromatous. The profunda femoris is large
and pervious down to the last perforating artery. Here the last perforat-
ing artery penetrates the adductor magnus and is continued pervious
on the posterior surface of the specimen. The artery itself terminates
close to the ridge of bone from the linea aspera in a mass of dense
cicatricial tissue. An artery, apparently the continuation of this,
emerges from the posterior surface of the specimen, from the cicatri-
cial tissue, contains a thrombus, and is lost on the posterior surface of
the adductor magnus. A single large vein accompanies the profunda
artery, passes beneath the last perforating artery, and terminates ab-
ruptly in the cicatricial tissue. The cicatricial mass is about two inches
in length, involves the attachment of the adductor magnus to the bone,
and is connected with the cicatrix mentioned above. A large vein, not
accompanying any artery, passes from below upward into the cicatricial
tissue, and terminates in a small, irregular, almost obliterated cavity,
partly filled with decolorized fibrin. It seems probable that a varicose
vein accompanying a terminal branch of the profunda artery ruptured
in or close to the attachment of the adductor magnus and gave rise to
the haematoma, and that the terminal branch of the artery was liga-
tured during the operation.
Dr. Sands said that the specimen confirmed the opinion that
the tumor was not aneurysmal, but was a venous tumor caused
by rupture of a profunda vein, and it was possible that the de-
termining cause of the rupture was the presence of a sharp
ridge of bone springing from the femur. When the sac was
emptied of clots, and before the tourniquet was applied, some
fresh blood escaped, but, judging only from its color, he was un-
able to say positively whether it was venous or arterial; but the
vessel in which the opening existed was of such large size that
he had no doubt of its being a vein. The aneurysm-needle
used was a rather sharp one, and in using it he punctured an
artery, which, when the tourniquet was loosened, permitted
hemorrhage ; but that point was at a considerable distance from
the opening in the large vessel ligated. As the bleeding vein,
owing to its deep situation and the condensation of the sur-
rounding tissues, could not be isolated, the ligatures must have
embraced the profunda artery as well as the vein. The blood
also which Mowed from the vein was very dark-colored.
A Contribution to the iEtiology of Malignant Tumors.
— Dr. R. J. Hall read the following paper:
So much of an almost purely speculative character has been
written during the last few years on the retiology of malignant
tumors that, did this paper contain merely a new hypothesis, I
should scarcely venture to present it to the society. It consists,
however, chiefly of a series of cases, most of which have come
under my own observation, which, in my judgment, strongly
support that hypothesis which is slowly but surely working
its way into the minds of most thinking pathologists and sur-
geons. I refer to the hypothesis which attributes these mys-
terious neoplasms to a specific virus, in all probability a micro-
organism.
"Without stopping to give an accurate definition of the term
493
tumor in general, it may be sufficient to say that by malignant
tumors we mean such as invade the neighboring tissues and
produce metastases (Ziegler, " Lehrb. d. allg. u. spec. path.
Anat.," 2te Aufl., ler Th., S. 214; Nidopel, Care. u. Infl.,
"Med. Jahrb.," 1883, S. 123), and that all such tumors are in-
cluded in two great classes, carcinoma and sarcoma. In regard
to the first of these, almost all pathologists have accepted Wal-
deyer's view, that the cells which occupy the alveoli are epithe-
lial, and the tumors therefore essentially of epithelial origin;
while there is no doubt whatever that the sarcomata are built
up of connective-tissue elements.
The theories hitherto formulated in regard to the origin of
these tumors have been so well classified by Dr. H. F. Formad,
in an exhaustive paper on the same subject (^Etiology of Tu-
mors, "Trans, of the Path. Soc, of Phila.," Sept., 1879, to July,
1881), that I can not do better than reproduce his classification.
Under each heading he has given a list of the pathologists who
have supported the hypothesis. The list is as follows :
1. Predisposition and Inflammation Theory. — Virchow, S.
D. Gross, Woodward, Samuel, Wagner, Birch-Hirschfeld, Cornil
and Ranvier, Perls, Tyson, S. W. Fitz, Gross.
2. Dyscrasia Theory.— Rokitansky, Paget, Billroth, Simon.
3. Embryonal Theory. — Cohnheim, Thiersch, Waldeyer,
Lticke, Masse, Hasse, Epstein.
4. Idiopathic or Spontaneous Theory. — Rindfleisch, Strieker,
Nancrede, Payne.
5. Nervous Theory. — Van der Kolk, Lang, Snow.
The nervous theory is, I think I may safely say, too fanciful
to merit discussion, except when considered as a possible pre-
disposing cause. The idiopathic and dyscrasia theories mean
nothing, the terms themselves being mere words which either
confess our ignorance or serve as a cloak to hide it. Cohn-
heim's, or the embryonal theory, which has lately fallen into
some discredit, undoubtedly offers a satisfactory explanation of
the origin of some benign tumors, and may afford a beautiful
explanation of one of the facts in regard to the structure of
many malignant tumors apparently most difficult to reconcile
with our hypothesis. For, if in certain regions, as the parotid,
embryonic remains are of frequent or constant occurrence, and
in others occur rarely or not at all, we can understand why in
the one case the same irritant should give us a mjxed, and in
the other a simple tumor.
There remains, then, only the predisposition and inflamma-
tion theory. Under the great authority of Virchow, patholo-
gists have been ready enough to accept this last as a sufficient
explanation ; that they have been, and are still, very slow to
recognize that the inflammation is of a specific kind, is due, I
think, chiefly to the following causes: WheD, following closely
on his " Cellular Pathology," it was demonstrated by Virchow
that tumors consisted of cells not differing genetically from
those found in normal tissues, the discovery excited such enthu-
siasm that many were convinced that the life-history of the cell
alone could sufficiently account for all the phenomena. Thus,
according to the widely accepted view of Thiersch, iu old age
the resistance of the connective tissue is diminished, the inter-
stitial spaces are widened ; under some local irritation the deeper
epithelial layers proliferate and penetrate the underlying tissues*
enter the lymph-spaces, and are swept into the neighboring
lymphatic glands, where, in accordance with their life-history,
they develop indefinitely, and, not being on a surface where
constant desquamation can occur, must do so at the expense of
the surrounding tissues. Thiersch, while correctly recognizing
the inflammatory character of at least one group of malignant
tumors, the carcinomata, could not at that time make the dis-
tinction, now clearly recognized, between simple or non-infect-
ive inflammations and infective; and his followers, with less
PROCEEDINGS OF SOCIETIES.
494
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Joub.,
excuse, refuse to do so even now. We have many instances of
local infective inflammations giving rise to metastases — not one,
so far as I know, of the non-infective. The view that malignant
tumors are of inflammatory origin is one which has spread wide-
ly among pathologists, especially since it has been found neces-
sary to place the so-called granulomata, tubercle, lepra, and
syphilis among the inflammatory diseases. The points of analo-
gy between these and the malignant tumors are too numerous
and obvious to have escaped observation. They have been pre-
sented at length by Dr. Formad in an exhaustive paper, and by
Dr. Nidopel. Time will only permit me to discuss them briefly
to-night.
Tubercle, which may be taken as the representative of the
granulomata, was long considered to be an ordinary inflamma-
tion in a tissue predisposed to disease; this is the standpoint
which many pathologists occupy at present in regard to malig-
nant di sease. It is interesting to note Formad (The Bacillus
tuberculosis, and some Anatomical Points which Suggest the
Refutation of its ^Etiological Relation with Tuberculosis,
" Phila. Med. Times," Nov. 18, 1882), whose weakness for pe-
culiarities in the lymphatic system as sufficient to account for
the origin of tubercle led him to reject the tubercle bacillus, and
brought down on him what can only be described as the annihi-
lating criticisms of Professor Koch (Krit. Besprechung d. gegen
d. Bedeutung der Tuberkelbacillen gerichteten Publicationen,
"Dtsch.med. Wchnschr.," Nov. 10, 1883), and Dr. Shakespeare
(A Criticism of Dr. Formad's Statements, etc., " N. Y. Med.
Jour.," Aug. 16, 1884) finds, in the absence of the endothelium
of the lymph-spaces, in carcinomata and sarcomata, a sufficient
explanation of their peculiar growth.
Numerous attempts have been made to show that the ana-
tomical peculiarities of tubercle tissue — epithelioid cells, giant
cells, cheesy degeneration — are sufficient to account for all the
peculiarities of the disease. The researches of Baumgarten
("Ztschr. f. klin. Med.," ix) and Weigert ("Dtsch. med. Wchn-
schr.," 1885, No. 35; quoted in "Med. News," Oct. 10, 1885)
show that they represent only the reaction of the enfeebled
cells under the irritation caused by the bacillus. A pathologist
can hardly fail to be struck by the similarity of the enormously
hypertrophied cells almost constantly found in sarcomata and
carcinomata .to the epithelioid and giant cells of tubercle, while
the frequency with which they are found in a state of fatty de-
generation and the readiness with which they undergo sponta-
neous necrosis remind us forcibly of cheesy degeneration. The
discussion has not yet quite terminated among pathologists as
to whether tubercle tissue always differs so much from other
inflammatory products as to make the microscopic diagnosis
possible in every case. In the same way the exact line between
certain sarcomata and the products of chronic inflammation has
never yet been drawn, while that form of tubercular skin dis-
ease known as lupus papillaris or verrucaseis, commonest on the
dorsum of the hand, and of undoubted inflammatory origin, is,
as I have myself had occasion to observe, indistinguishable
under the microscope from epithelioma (Doutrelepont, " Ber.
lib. d. Verhandl. d. dtsch. Ges. f. Chir.," 1885— Disk. lib. Tuber-
kulose, Volkmann). Into what absurdities we may be led by
regarding carcinoma as merely a new specific inflammatory pro-
cess is well shown by the statement of Formad (^Etiology of
Tumors) that there are great numbers of chronic ulcers of the
leg in the Philadelphia hospitals, and that a large proportion of
them are carcinomata, because he has found epithelial nests and
proliferation of the interpapillary epithelium. Both tuberculo-
sis, as seen by the surgeon, and malignant tumors are distinctly
associated with traumatisms. Thus, Volkmann states that the
great majority of tubercular bone and joint diseases are refera-
ble to an injury (Erfahrungen iib. d. Tuberkulose, "Verh. d.
dtsch. Gesellsch. f. Chir.," 1885), while Formad alleges that he
finds an inflammatory origin in nearly one half of all tumors.
Dr. D. G. Zesas (Zur Kasuist. d. traumat. Tumoren, " Wien.
med. Wchnschr.," 1883, No. 40; see also C. Mazzohi, Ueb. d.
Sarkom., "Arch, di Med., Chir.," etc., vi, 40, f. 201, quoted in
"Ctrlbl. f. Chir.," 1874, S. 169 [three cases of sarcoma after
operationj ; M. Landesberg, Zur Aetiol. u. Progn. intra- u. extra-
ocularen Sarcoma, Virchow's "Arch.," Jxiii, p. 1, 1875 [a case
of sarcoma following an acute suppurative iridochoroiditis] ; R.
Barwell, On Acute Traumatic Malignancy, "Brit. Med. Jour.,"
Feb. 11, 1882 [gives several cases of sarcoma directly after in-
jury]) quotes S. Wolff's statistics drawn from tumor cases ob-
served in the surgical clinic at Berlin between 1864 and 1873,
according to which, in 344 cases of carcinoma, a trauma was
given as the cause 42 times, and in 100 of sarcoma 20 times.
It is well known that sarcomata usually follow a single in-
jury, and carcinomata a long-continued irritation. The reverse
is, however, by no means unknown. Thus, Weil (Sarcoma
hamiorrhagicum, " Prag. Vierteljahresschr.," xxxiv, 4, 1877, p.
1, abstract in Schmidt's " Jahrb.," 185, S. 97) gives two cases
of sarcoma attributed to repeated irritation.
Dr. R. F. Weir ("Am. Jour, of the Med. Sci.," April, 1876,
p. 407) has reported a case of scirrhus of the penis following a
contusion received four months previously, and refers to a simi-
lar case reported by Holmes Coote (" Med. -chir. Trans.," xlvii,
1863 ; see also Geber, Epithelialcarcinoma des Penis nach
Coitus, " Wien. med. Presse," xii, 4, Jan., 1871, abstract in
Schmidt's " Jahrb.," 160, p. 88). J. W. Hulke ("Med. Times
and Gaz.," Feb. 8, 1873; reports a case, occurring in amanaged
sixty-eight, in which a small wound of the palate, made by the
stem of a pipe driven into the mouth, was followed in a month
by a small " wart," which grew rapidly and, six months after
extirpation, recurred, extended rapidly, and caused the death of
the patient. Microscopic examination proved the tumor to be
an epithelioma.
If we deny the existence of a specific virus in these cases,
we are compelled to fall back upon the vague term predisposi-
tion, which was formerly used to explain the cases of tubercular
disease having a similar origin. On the hypothesis of a non-
specific inflammatory origin it would be difficult to account for
the fact that in some countries malignant tumors are practically
unknown (Formad, "^Etiology of Tumors"). For, surely, con-
tusions and chronic inflammatoy processes, with diminished re-
sisting power on the part of the connective tissue, can not be
wholly wanting in thes^e places. One of the strongest objec-
tions made to the assumption of a specific poison in the case of
malignant diseases has been the absence of any evidence of con-
tagion. Cohnheim (" Allg. Pathol.," 1877, quoted by Formad,
he. cit.) denied the existence of a specific poison, on the ground
that the surgeon was never infected from the patient, or the
husband from the wife. It is well to remember that precisely
the same objection was made to the tubercular bacillus. Many
physicians of large experience declared that they had never
seen a case of even probable tubercular infection, yet now the
journals are filled with them, and, while the surgeon seems still
to be safe, the anatomist has not been spared (Cohnheim, op.
cit.).
It is to meet this objection that I have ventured to present
the following cases. Three of the series are from the practice
of Dr. Sands, and one or both of the patients concerned in each
case have come under my own observation ; for the fourth I
am indebted to Dr. Markoe, and the fifth was seen at the Out-
door Department of the Roosevelt Hospital by myself :
Case I. — Mr. Thomas E. C, aged forty, married, New York, clerk,
admitted to Roosevelt Hospital December 3, 1878. Family history
good. Patient has varicocele on the left side, and a tumor of the
Oct. 31, 1885.]
PROCEEDINGS
OF SOCIETIES.
495
left testicle, of twenty-two months' growth, of the size of a eocoanut,
smooth, firm, and of fibrous consistence. Extirpation of the tumor,
January 8, 1879, by Dr. Sands; death, January 26th, from suppression
of urine due to pressure on the ureters by metastatic growths in the
abdominal cavity. Microscopic examination by Dr. Delafield showed
the tumor of the testicle and those in the abdominal cavity to be en-
cephaloid carcinoma (Karg, Tuberkelbacilli in einem sog. Leichentu-
berkel, "Ctrlbl. f. Chir.," 1885, No. 32; G. Ricke, ibid., 1885, No. 36).
Mr. C.'s widow, subsequently married, Margaret Anne, New York
city, aged fifty years and three months, died, while under my care, April
12, 1885, with carcinoma " en cuirasse," originating in the mamma?.
The tumors were stated to have been first noticed in 1882, and in both
breasts at the same time. The growth was confined to the mammary
glands and the skin ; no enlargement of the axillary glands occurred,
and only superficial ulceration of the carcinoma. Death was due to re-
peated haemorrhages from the ulcerating surfaces and to exhaustion. No
autopsy was obtained. Mrs. L.'s mother, Mary Anne D., died January
30, 1885, aged eighty-one years and six months, of acute bronchitis
and broncho-pneumonia. One month before her death the patient
consulted me with regard to a rapidly-growing tumor of the right
breast which she had first noticed one month previously. My diagnosis
was probable carcinoma. The tumor was seen also by Dr. Sands, who
concurred with me. The family history of this patient was good. Espe-
cially there was no history of tumors. She had been a good deal with
her daughter during the illness of the latter, but did not live in the
same house. No autopsy was obtained.
Case II. — Mrs. D., aged forty-three, with a good family history, was
subjected to operation by Dr. Sands, on May 3, 1882, for carcinoma of
the right breast of one year's duration. Recurrence took place about
six months later, and the patient died about April, 1883. Microscopic
examination by Dr. Satterthwaite showed the tumor to be scirrhous car-
cinoma. Mr. George D., aged forty-seven, husband of the last patient,
came under observation October 20, 1882, suffering from a tumor of the
superior maxilla. A younger brother died five years ago of what was
said to be recurrent sarcoma of the testicle. The family history was
otherwise good. About three months ago the patient noticed a swelling
in the left superior maxillary region, and thought he noticed a hard lump
beneath the left angle of the lower jaw some time before this. Both
tumors have grown rapidly since. A tumor of soft consistence occu-
pies the situation of the left superior maxilla, and extends in the direc-
tion of the malar bone. There is a mass of enlarged glands beneat h the
left angle of the lower jaw. Extirpation of the tumor and enlarged
glands was performed by Dr. Sands. Rapid recurrence took place, and
death in May, 1883. Microscopic examination showed the tumor to be
an epithelioma.
Case III. — Miss Isabella S. was admitted to Roosevelt Hospital, May
25, 1885, suffering from a rapidly growing tumor involving the right
superior maxilla and said to be of three months' duration. Extirpation
of the superior maxilla was done by Dr. Sands, May 27, 1885. Death
occurred from shock and luemorrhage following the operation. Micro-
scopic examination showed the tumor to be a giant-celled sarcoma. Mr.
F. J. G., aged twenty, single, was engaged to Miss S. for some months
before her death. He was submitted to a surgical operation on Septem-
ber 9, 1885, by Dr. Post, for the removal of a small cystic tumor of the
right superior maxilla, said to be of only three weeks' duration. The
tumor lay in front of the antrum, and did not occupy its cavity. Micro-
scopic examination showed it to be a giant-celled sarcoma.
Case IV (taken from Dr. Markoe's work on " Diseases of the Bones,"
New York, 1872). — Mrs. S. N. E., aged about twenty-three, consulted
Dr. Markoe, March 26, 1866, for a small tumor occupying the right side
of the neck, behind the steruo-mastoid, and of about the size of a hick-
ory nut. An operation was performed May 1, 1866, when the tumor
was found closely attached to the transverse process of the fourth cer-
vical vertebra. Recurrence took place after a few months, followed by
slow growth until April 10, 1869, when a second operation was per-
formed. Recurrence took place in the autumn of 1869, with gradually
increasing paralysis due to pressure on the spinal cord. A third opera-
tion was done .h ary 25, 1871, followed by complete relief of all the
symptoms, and there has been no recurrence up to the present time.
Microscopic examination by Dr. Delafield showed the tumor to be a
myxo-sarcoma. Mr. E., aged fifty-six, husband of the last patient, under-
went, on January 19, 1885, an exploratory incision of the abdomen to
determine the nature of an abdominal tumor, the symptoms of which
dated from December, 1884. A soft, friable tumor was found matting
the viscera together in such a way as to prevent the possibility of its
removal. The tumor was considered by Dr. Markoe to be a sarcoma,
probably originating in the great omentum. The patient died about
three days"after the operation. No autopsy was obtained.
Case V. — Thomas C, of New York, aged fifty-three, September 4,
1885. Family and personal history good. Especially there was no
history of tumors or syphilis. Sixteen years ago he broke his left arm
near the elbow, but recovered without stiffness or deformity. One
month ago the left elbow and the right ankle became swollen, and the
swelling has increased rapidly since, without pain, redness, or tender-
ness, except over the internal malleolus, where the pain is quite severe.
Examination shows that the inferior extremities of the left humerus
and the right tibia are expanded, so as to form distinct tumors of the
lower ends of the bones, the tumors being smooth and of bony hardness.
The neighboring bones and articulations are unaffected. A diagnosis
was made of simultaneous sarcoma of the humerus and tibia. The
patient was examined by a number of surgeons, who all concurred in
the diagnosis. The tumors were especially unlike, in their growth and
character, syphilitic or tubercular deposits, which almost alone might be
supposed to come into consideration.
While taking the patient's history I incidentally elicited the fact that
his wife had died last February, after a six-weeks' illness, with rapidly
advancing hemiplegia of the left side, and that the diagnosis of the
attending physician, Dr. A. R. Robinson, of this city, was tumor of the
brain. Dr. Robinson, whose well-known skill as a pathologist lends
weight to the diagnosis, informs me that the case was a well-marked
one of rapidly growing tumor of the brain involving the motor areas
about the fissure of Rolando, and, so far as the diagnosis could be made
clinically, undoubtedly sarcoma. Syphilis especially was carefully ex-
cluded.
I am well aware that these cases are not beyond criticism,
especially on the ground of the absence, in some of them, of a
microscopic examination. This, however, was unavoidable, and
in none of the cases, except possibly the last, could there be
much real doubt as to the nature of the disease.
In Case IV the long interval which appeared to exist be-
tween the last appearance of the disease in the wife and its oc-
currence in the husband may seem to deprive the case of all
significance. When we consider, however, the extremely slow
growth of the original tumor, as seen in Mrs. E., and how long
a similar one might exist in the abdominal cavity without giving
rise to symptoms, the objection loses much of its weight. The
length of time also that a tumor histologically malignant may
remain latent, as contrasted with the frequently rapid growth
of the same or similar tumors, is, I think, not sufficiently appre-
ciated by pathologists, and offers another striking analogy to
tubercular deposits. When a tumor which has remained quies-
cent for many years begins to grow and takes on the character
of malignancy, surgeons are apt to assume that it has undergone
a histological change from a benign to a malignant growth.
The following cases tend to prove that at least sometimes the
assumption is unwarrantable :
Case VI. — A small tumor, about half an inch in length by a quarter
of an inch in width, adherent to the skin, but situated in the subcuta-
neous connective tissue, was removed by Dr. Markoe from the back of
a healthy man, where it had existed for many years, with, I am in-
formed, little or no change during that time. The tumor is a small-
rouud-and-spindle-celled sarcoma, with little intercellular substance and
having histologically all the characters of malignancv.
Case VII. — Minnie M., aged eighteen, single, of good family history,
noticed a tumor of the neck, below the lobe of the left ear, three vears
ago. The tumor is of about the size of a pigeon's egg, and resembles a
conglomerate of enlarged lymphatics. She states that it has scarcely
grown or altered since it was first noticed. Extirpation was done May
406
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jolb.,
25, 1885. Microscopic examination shows it to be a mvxo-sarcoma and
histologically very malignant.
Case VIII. — Miss T. had a tumor in the same region, precisely
similar to the former. She was a healthy woman, aged twenty-one.
The tumor had existed for five or six years and grown almost imper-
ceptibly. She desired operation only because a brother had died about
one year previously of sarcoma of the pharynx. Extirpation was done
by Dr. Sands January 23, 1884. Microscopic examination showed the
tumor to be of almost exactly similar structure to the last.
The possibility of direct inoculation of the human subject or
of animals with malignant disease has been much discussed, and
many experiments have been made with generally negative or
doubtful results. I have only been able to find in the literature
of the subject two at all well authenticated cases of apparent
inoculation. Meissner (Ueb. Krebs, Schmidt's "Jahrb.," 126,
p. 121) states that, in 104 cases of melanotic sarcoma, one pa-
tient gave inoculation from ahorse with the same disease as the
cause. In the discussion on Dr. Formad's ("^Etiology of Tu-
mors"; see also Kuhn, Note sur un cas de cancer medullaire
transmis par inoculation d'un animal a l'homme, "Gaz. med.
de Paris," xvi, 1861, pp. 263, 391, 405) paper, Dr. S. W. Gross
quoted from the "Mag. fur die ges. Thierheilkunde," 1862. p.
328, the case of an ulcerating medullary sarcoma in an ox. A
woman who cleaned the sore every day acquired a tumor of the
outer side of the fourth finger of the left hand. Kuhn exam-
ined the tumor and found it to be a medullary sarcoma. Among
cases of supposed contagion which can scarcely be accepted as
evidence, Hynerth (De l'inoculation de cancer chez le lapin,
" Gaz. des hop.," 1873) refers to cases of contagion reported by
Tulpius (" Nicolai Tulpii Amstelodamensis observationes medi-
cse," ed. nova, Amstelodami, CIqIXLXXII ; apud "Danielem
Elsevirium observ. med.," Lib. iv, p. 292, 1672 [New York Hos-
pital Library, No. 255]), and to those to which have been at-
tributed the deaths of Smith and Bellinger. In a discussion by
Dr. Munde ("N. Y. Med. Jour.," Oct. 27, 1883) on cancer of
the penis and contagion, the author states that Demarquay, in
an analysis of 134 ca*es, found one where local contagion was
alleged, and that Dr. Welch quotes Langenbeck as saying that-
he had seen three or four cases caused in the same way. Dr. T.
Gaillard Thomas (abstract in "Med. Record," Nov. 7, 1883, p.
547) states that he has only met with one case of cancer of the
penis in which contagion seemed to be probable.
There are a great number of unsuccessful or doubtful inocu-
lations of animals, for an account of which I must refer to the
general literature, and especially to Dr. Formad's article. The
only experiments which seem beyond question are those of Pro-
fessor Klincke (Haser's " Arch. f. d. ges. Med.," iv, 4, 1843,
quoted in Schmidt's "Jahrb.," 126, S. 91), who inoculated a dog
in the jugular vein and a horse in the conjunctiva with juice
from a pigment carcinoma, taken from a mare. In the horse,
in sixteen weeks the lachrymal gland was transformed into a
melanotic tumor; the dog died in three months, and melanotic-
tumor masses were found in the lungs.
Novinski (Zur Frage lib. d. Impfung d. krebsigen Gesch wulste,
"Ctrlbl. d. med. Wiss.," xiv, 1876, p. 790) made twenty-seven
inoculations of carcinoma from the nose of a dog into inflamed
tissue, and fifteen into normal skin. All of the first were nega-
tive; two of the last positive. In the successful experiment, a
small piece of carcinoma (2 mm.) was introduced into a fresh
wound of the skin of the back. The wound healed per prima m.
In fourteen days the fragment had reached the size of a pea, and
in three months that of a walnut. Four months after the inocu-
lation the dog was killed. The tumor measured 3*5 ctm. in
diameter, and was soft and white in section. The lymphatic
glands in the subclavicular region were much swollen. Micro-
scopic examination of the tumor showed the peripheral part to
be made up of closely lying polygonal cells, of epithelial character
and varying in size, infiltrating the surrounding connective tissue.
In the center there were alveoli of various sizes, with more or less
fine tubercles and similar epithelial cells. The same structure
occurred in the lymphatic glands. A young dog was then inocu-
lated with a piei-e of this tumor, but died n fortnight later (of
" Pextkrankheit"1). Examination showed a small tumor at the
point of inoculation ; there were no metastases. The tumor
showed a typical cancerous structure.
Dr. Goujou ("Gaz. des hop.," 1867, No. 85) gives two cases
which do not appear quite so conclusive. He injected melanotic
masses into the left thigh of a dog, and killed the animal after
two weeks. At the point of injection there was found a mela-
notic tumor of the size of a Thaler ; also pigment in the lymph-
vessels and neighboring lymphatic glands. The lymphatic
glands, including the bronchial, were enlarged and pigmented.
The lungs were free. The same material was injected iuto
the peritoneal cavity of a second dog, which was killed forty-
three days later. At the point of injection and in the mesen-
tery there were deposits of pigment. In one horn of the uterus
there were two pigmented tumors. Few glands were affected;
one inguinal gland was much enlarged. The bronchial glands
were pigmented, but possibly this was from the lungs. All the
pigment was in epithelial cells, but these were not similar to
those of the tumor injected.
There is another way, however, of studying the subject. It
will not be denied that there is not at present a pathologist of
eminence who does not teach that malignant tumors are at first
purely local. Could it be shown that sarcoma and carcinoma
could be transmitted from man to man, or from man to animals,
the idea that nothing but the cell was inoculated would not be
able to hold its place in scientific opinion for six months. We
have passed the stage when it was possible to believe that an
infectious disease could be of spontaneous origin. Yet, if the
disease is at first purely local, the inoculation of a distant por-
tion of the body in the same patient, the so-called "contact-
infection," is as valuable as the inoculation of another person
would be. Cases of this kind are not rare in literature. The
chief recorded instances are the following:
Dr. M. Nedopil (Joe. cit.) quotes a case, narrated by Liicke,
of ulcerated carcinoma of the edge of the tongue, with inocula-
tion of the mucous membrane of the cheek on the same side;
a case by Kaufmann, in which a woman had cancer of the dor-
sum of the right hand, and subsequently of the conjunctiva of
the right eye ; her relatives stated that she constantly wiped
the right eye with the back of the right hand ; cases by Ahl-
feld (Beitrag zur Casuistik d. TJterussarkome, "Arch. f. Gynak.,"
vii, 2, p. 301), Hegar (ibid., ii), and Spiegelberg (ibid., iv), of
direct inoculation of the vagina from the uterus ; and cases by
Klebs of inoculation of cancer of the tongue, in the stomach.
J. Reincke (Virchow's " Arch.," li, 3, p. 391) gives two cases
in which carcinoma developed in the punctures made to relieve
ascites due to carcinomatous peritonitis. Professor H. Quincke
(Ueb. fetthaltige Transsudate, "Dtsch. Arch. f. klin. Med.,"
xvi, 2, p. 121) gives a similar case. C. Partsch ("Das Carcino-
ma," etc., Breslau), in giving statistics of carcinoma of the lips,
penis, and vulva, relates one case of possible contact-infection.
P. Kraske (Ueb. d. Entstehung secundiiren Krebsgeschwulste
durch Impfung, "Ctrlbl. f. Chir.," 1884, No. 48) gives two
cases of rectal carcinoma in which small secondary tumors were
found at a lower point, separated by healthy mucous membrane
from the primary growth, and refers to Virchow's well-known
observation on the peculiar distribution of carcinoma of the
peritonaeum, secondary to carcinoma of the stomach (Virchow,
" Die krankhaften Geschwulste," i, p. 54) ; to the cases of Liicke
(Die Lehre von den Gesch wiilsten, etc., Billroth u. Pitha's
Oct. 31, 1885.]
PROCEEDINGS OF SOCIETIES.
497
"Hahdbuoh," ii, 1, S. 50), Kaufmann (Ueb. Multiplicitiit d.
prim. Carcinoma, Virchow's " Arcb.," lxxx, p. 347), and Klebs,
mentioned above, and to a case by Erbse, in which a carcinoma
of the oesophagus perforated the trachea and gave rise to sec-
ondary tumors in the lower lobes of the lungs.
Beck (Beitrage zur Gesch wulstlehre, "Ztschr. f. Ileilk.," v,
6, 1884, abstract in " Otrlbl. f. Chir.," 1885, No. 34) records the
following three cases from the Institute of Chiari, Prague. 1.
Ulcerating cancer of the oesophagus. In the anterior part of the
lower end of the oesophagus and in the stomach there was a
tumor of the same character, flat-epithelial carcinoma. 2. Two
carcinomata of the oesophagus separated by healthy tissue. The
author admits the possibility of both being primary. 3. Multi-
ple lymphadenoid round-celled sarcoma of most of the lymphatic
glands, the lungs, spleen, and posterior surface of the stomach.
In the ileum there were numerous similar nodules, not corre-
sponding to Peyer's patches. In the caecum there was an in-
filtration of almost the whole intestinal wall. The author
excludes, on various grounds, all the other situations, and con-
siders the growth in the cascum as primary, and the other
tumors in the intestinal tract as due to contact-infection, the
tumor particles being carried back by antiperistalsis, the tumor of
the caecum being ulcerated and having caused much obstruction.
Beck quotes also a case, by Iljelt, of carcinoma of the ileum
and colon, with primary cancer of the duodenum.
Two cases of the kind have come under my own observation,
as follows :
Case IX. — Mr. A., an elderly gentleman, probably between fifty and
sixty, suffered for several years from a slowly growing epithelioma of
the floor of the mouth, on the left side, and encroaching on the pos-
terior surface of the gums. Several operations were performed by Dr.
Sands at varying intervals, with temporary success ; but recurrence took
place after periods varying from two or three years to several months.
After the fourth operation, December 18, 1884, rapid recurrence took
place. A flat epithelioma developed on the hard palate, just at the
point where the tip of the tongue, constantly in contact with the epi-
thelioma in the floor of the mouth, would frequently impinge. The
diagnosis in this case was confirmed by repeated microscopic examina-
tions.
Case X. — Mary M., aged forty-four, single, March 29, 1885. Fami-
ly history good ; no case of malignant disease known. Carcinoma of
the right mamma, first noticed two years ago. Amputation of the
breast was performed one year later. The axilla was nftt opened. Re-
currence was noticed last October. Patient was first seen March 29,
1885, suffering from carcinoma, recurrent in the cicatrix of the opera-
tion, the new growth extending in the form of nodular masses, ulcer-
ated in part, over almost the whole right side of thorax, anteriorly,
laterally, and posteriorly to the external border of the scapula. The
axillary glands on the same side were much enlarged, and the whole
right upper extremity was enormously swollen, oedematous, and pain-
ful. On the left side of thorax, above the mamma, and on the left
shoulder, were several isolated, non-ulcerated, cancerous nodules, vary-
ing in size from that of a split pea to three quarters of an inch in
diameter, and not extending beneath the skin. There was a profuse
sero-purulent discharge from the ulcers. The patient was last seen
June 23, 1885, when the carcinoma had extended over the upper part
of the abdomen and a great part of the right scapula and shoulder.
Ulceration of the carcinomatous masses in the axilla had occurred. The
discharge from the ulcers on the shoulder and in the axilla constantly
ran down on the anterior and internal surfaces of the arm and forearm
to the wrist, exciting an eczema and inducing the patient to scratch.
All along (his surface there were cancerous nodules in the skin, generally
ulcerated, or excoriated on the surface ; some isolated, others confluent,
and extending to the wrist. She died of exhaustion July 10, 1885.
I may mention here one or two more interesting points of
analogy between tubercle and malignant tumors. The former
appears usually as a more or less chronic and localized disease.
It occurs also as an acute infectious disease. Acute miliary
tuberculosis involving the different organs with a rapidity that
was a complete mystery to the pathologist until the views of
Weigert (Ueb. Venentuberculose u. ibre Beziehung zur tuberc.
Blutinfection, Virchow's " Arch.," Ixxvii, p. 269, lxxxviii, p.
307 ; Neue Mittheil. ilb. d. Pathol, d. acut. allg. Tuberculose,
"Dtsch. med. Wchnschr.," 1884, No. 24), founded on careful
anatomical research, were confirmed by the demonstration by
Weichselbaum (Bacillen im Blute boi allg. acuter Miliartuber-
culose, " Wien. med. Wchnschr.," 1884, 12, 13), Baumgarten
("Otrlbl. f. d. med. Wiss.," 1881, 15), and others, of tubercle
bacilli in the blood. Raymond and Brodeur (" France med.,"
1883) record a case of primary acute miliary carcinosis, and
refer to two similar cases by Charcot. Numerous cases have
been reported, during the last few years, of general tuberculosis
following operation on a local process, the operative interfer-
ence having obviously opened the way for the bacilli into
the general circulation (Koenig, "Bericht d. xiii. dtsch. chir.
Congr." ; also Tuberculose d. Knochen u. Gelenke, and Szu-
man, Brisement force eines scrophulosentziindeten Kniegelenks
etc., "Otrlbl. f. Chir.," 1885, No. 29; P. Aubert, Le traitement
du lupus a l'Antiquaille, "Ann. de dermat. et de syph.," iv, 3
[two cases of rapidly fatal phthisis pulmonum shortly after scari-
fication of lupus]). A precisely similar general cancerous infec-
tion has been reported by Schweninger ("Bayer, arztl. Intell.-
Bl.," xxiii, 32) as follows : A girl, aged seventeen, underwent
an operation for colloid carcinoma of both ovaries. The tumors
were punctured shortly before the operation for diagnostic pur-
poses. During the operation one of the tumors was torn. No-
reaction took place, and the wound practically healed in ten or
eleven days. From this time there was a continued fever of
remittent character, with diminished power and sensibility in
the left arm and leg, and severe neuralgic pains and cramps in
the affected extremities. Rapid extension of these symptoms
took place to the right side, followed by bronchial catarrh, in-
creasing weakness, and death, thirty-six days after the opera-
tion. A post-mortem examination showed that the peritonaeum
was thickly covered with carcinomatous nodules, varying in
size from that of the head of a pin to that of a pea. Similar
nodules were found in the liver, in the spleen, beneath the
pleura, in the parenchyma of the lungs, and on the surface of
the dura mater. In the interior of the brain there was a colloid
tumor of about the size of a hen's egg.
Finally, it is with some hesitation that I state that I have
found bacilli in a single case of rapidly growing, non-ulcerated,
large-celled sarcoma of the occipital region occurring in a
woman, and extirpated by Dr. Sands during the past year. The
tumor tissue had been kept in ninety-five-per-cent. alcohol since
the operation, and the sections were stained with fuchsin by a
slight modification of de Giacomi's method for staining the ba-
cillus of Lustgarten (Friedliinder's " Fortschritte der Med.,"
1885, 16, p. 543). The modification consisted merely in more
prolonged immersion in the staining fluid, and may not have
been essential. Every precaution was taken in the way of
using sterilized vessels, reagents, etc. Of two sections exam-
ined, bacilli were found very sparingly in only one, and after
prolonged examination. The examination was made with a
Zeiss oil-immersion T'j, and Verick eye-piece No. 3, using, of
course, the Abbe condenser. Though few in number, the ba-
cilli found were very distinct, only one being situated in each
cell, straight and apparently somewhat longer and plumper in
proportion to their length than the tubercle bacilli. I know
well, of course, that little or no scientific valuo attaches to a
single observation of this kind by one man, unsupported by the
evidence of any others, but mention it because it may acquire
some if confirmed by future research; and at least it serves to
498
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jouk.,
show tli. it my work is not all theoretical, but practical as well.
[The paper was followed by numerous references to literature.]
The Pkesident, referring to Cripps's latest work on " Dis-
eases of the Rectum," stated that the author considered epithe-
lioma of the rectum as probably parasitic in nature, which was
supported by the fact that in the underground workers of cer-
tain mines in Silesia sarcoma occurred very frequently, whereas
it did not prevail among those who lived in the adjacent coun-
try: and also that in the low lands' near Liverpool in England
there was no marked increase in the cases of cancer. The two
cases quoted in the paper under the initial D. had been finally
under his care, and they had struck him as bearing upon the
question of contagion closer than any others he had ever en-
countered.
Dr. A. C. Post said that one interesting feature of the tumor
upon which he had operated was that, although the morbid
growth did not extend into the antrum, it had eroded its ante-
rior wall so that he could pass his little finger into the cavity.
Dr. Sands was able to add another case to the list given by
Dr. Hall — one in which malignant disease occurred in more than
one member of the same family. A young man came to him
three years ago on account of a swelling on the right side of the
face over the spheno-maxillary and malar regions. It seemed
to be due to the development of a tumor which was very deeply
situated, and which, besides causing projection of the side of
the face, was attended with a protrusion of the eye. He sus-
pected the existence of a polypus of the spheno-maxillary fossa,
and, with a view to remove it, he raised the malar bone, but was
disappointed on discovering that, although a tumor was present
in the spheno-maxillary fossa, it was not a polypus, but was
firmly imbedded and could not be removed. The patient was
known to be living, six months ago, in a state of great misery,
the tumor having reached a very large size. About six months
ago a brother of this patient was brought, in whom a tumor of
large size had developed in the pharynx within a few months.
It filled the pharyngeal cavity, and, although it was not firm in
consistence, it was firmly attached. The disease was evidently
malignant. The patient's general health bad become very much
impaired, and the speaker had been obliged to decline surgical
interference. Probably both patients were now dead. They
lived in the same house in Westchester County, and often occu-
pied t lie same room.
It seemed to him that such cases, although they could not be
accepted as proving the contagiousness of malignant tumor, in-
dicated very clearly the direction in which future inquiries
should be made in the hope of confirming the hypothesis of the
parasitic nature of these morbid growths; for, certainly, there
was no disease not already proved to be parasitic which would
seem so likely as cancer to have such a mode of origin.
Dr. Hall remarked, with reference to the remarkable ab-
sence of cases of apparent contagion in literature, that it might
be explained by the fact that, if the idea of specific poisons for
malignant tumors was accepted, probably all cases recorded as
of hereditary origin would fall under the head of infection. In
tubercle practically the same thing was occurring now. For-
merly all cases had been attributed to heredity, whereas now
they were very largely attributed to infection. Congenital tu-
berculosis was extremely rare, and, while congenital carcinoma
and sarcoma occurred, they were also extremely rare.
NEW YORK ACADEMY OF MEDICINE.
Meeting of October 15, 1885.
The President, Dr. A. Jaoobi, in the Chair.
The Organization of the Section in Surgery was an-
nounced, Dr. Stephen Smith being Chairman, and Dr. A. B.
Jtidson Secretary ; the meetings to be held the second Monday
of each month.
The Final Payment on the Property of the Academy
was announced by Dr. F. A. Castle.
The Comparative Results of Operations in Bellevue
Hospital. — Dr. Stephen Smith read a paper with this title,
which was prefaced by this paragraph : " As we drift with cur-
rent events we but imperfectly estimate the real advance which
any art or science with which we are daily familiar has made
within a limited period. It is only when we considerately pause
and deliberately compare in detail past methods and results
with those now practiced and obtained that we fully appreciate
the vast changes which have so insidiously and imperceptibly
taken place."
He then pictured Bellevue Hospital as it was in former years,
located on the made lands of a cove of the East River, without
drainage, adequate sewerage, or ventilation — a receptacle of
typhus and typhoid fevers, small-pox, puerperal fever, cholera,
and yellow fever. Bellevue Hospital had seen little of surgery
before 1850; since then the increase of surgical practice in that
institution had been gradual. The methods of procedure had
been entirely revolutionized. Before the introduction of anaes-
thetics, the most important general principle governing the
operator was celerity, whereas now, while the surgeon aimed
to diminish the period of anaesthesia, mere haste was con-
demned. The surgeon's aim at present was to avoid suppura-
tion. Formerly he troubled himself only to keep his instru-
ments sharp, and paid little attention to cleanliness except as it
guarded against rust. Now one of the assistants gave his whole
attention to the instruments, placed them in a solution of car-
bolic acid, and took every means to render them clean. For-
merly patients were brought directly to the operating-table
without the part to be dressed or operated upon being even
washed. Now the greatest pains were taken to clean the seat
of the disease. Formerly the personal preparation of the sur-
geon and his assistants was only with a view to prevent soiling
their clothing. No thought was given to the hands or nails.
By-standers were invited to put their fingers into the wound
without previous cleansing. The sponges were cleansed only
in simple water; ligatures were carried in the surgeon's pocket;
but one end of the ligature was cut off, the other being left for
removal by traction after its final separation from the vessel.
In closing an ordinary wound, the surgeon formerly took great
pains to provide for the escape of pus, for he always expected
suppuration. The final dressing was of adhesive plaster, and
the bandage for support and retention. The plaster was never
rendered aseptic, and, by its close relations to the wound, was
dangerous. The bandage was usually of unbleached muslin,
and added to the risks of infection. The surgeon left many
wounds open which he would now close, for formerly he ex-
pected suppuration, while now he expected to avoid it. While
describing the practice before the introduction of anaesthesia
and antiseptics, Dr. Smith pointed out in contrast the methods
of to-day. If we followed the wounds treated by former and
by modern methods from the first to the last dressings, the con-
trast was remarkable. If the wound was large, on the second
or third day the fever formerly began, announcing suppuration,
and for weeks after the dressings were changed once, twice, or
oftener daily. The pu9-basin, irrigator, and dressing-forceps
were in constant demand; there were fever, exhaustion, and
depression of the patient, and then came chills, fever, and pro-
fuse sweatings, now called pyaemia, but then considered as only
another stage of surgical fever. But metastatic abscesses were
now things of the past. Everything was at present directed
toward the prevention of suppuration.
The author then contrasted the treatment formerly adopted
Oct. 31, 1885.1
PROCEEDINGS OF SOCIETIES.
499
in compound fractures, amputations, exsections, and ligations of
arteries, with that now practiced. Amputations were not now
thought of except where the nerves and arteries were so far
destroyed as to prevent the conveyance of nourishment to the
extremity. Formerly amputation wounds rarely, if ever, closed
at Bellevue Hospital except after long-continued suppuration,
and the larger ones were terrihly fatal, whereas now they were
among the most successful cases in the hospital, and death from
suppuration and its results did not occur. Formerly psoas and
other abscesses were allowed to go until they made an opening
for themselves. Now they were opened and washed out with
an antiseptic solution, often with the cessation of suppuration.
Their walls being approximated after scraping, they frequently
united almost at once. Septicaemia and pyaemia were now al-
* most unknown in the gynecological wards. Reviewing the
surgical practice of Bellevue, it was not difficult to determine
the essential feature of present methods as compared with those
of the past; it was cleanliness. The agents now found efficient
to secure this were soap and water to external parts, carbolic-
acid solution for the instruments, bichloride solution to all sur-
faces and tissues, and iodoform for external dressings.
Dr. A. C. Post was prepared to accept the author's state-
ments with regard to the thorough efficiency of cleanliness. He
thought there was still room for doubt as to how far the use of
antiseptics, so called, contributed to the success of operations
other than as it secured cleanliness. His reason for doubting
somewhat the part antiseptics played in contributing to the suc-
cessful treatment of wounds was founded on the experience of
the most eminent gynaecologists of Great Britain. Mr. Tait and
Mr. Keith, the most successful ovariotomists, had regarded anti-
septics, so called, as not only useless but pernicious ; they main-
tained that the use of antiseptics added a small percentage of
mortality to that class of operations. They both insisted, how-
ever, on thorough cleanliness. But there was no doubt of there
.having been a very great improvement in the treatment of sur-
gical wounds, whether we regarded the improvement as due to
antiseptic methods or to cleanliness.
Dr. W. Gill Wylie did not know whether we should have
learned the full meaning of cleanliness had it not been that anti-
septics, as introduced by Lister, had helped us to an understand-
ing of it. He had no doubt that antiseptics had done good, but,
like all things which had done good, they had been carried too
far, and there was now somewhat of a reaction against them.
He used antiseptics simply as a substitute for cleanliness, but
if he could be sure of perfect cleanliness he would not use anti-
septics.
Dr. Smith closed the discussion, and said that it had not
been his intention to treat specially of the subject of antiseptics.
Since the discussion had taken that direction, he might say,
however, that in his opinion the value of antiseptics rested in
their securing cleanliness. Extreme cleanliness now pervaded
the wards of Bellevue Hospital. It was especially necessary
that the surgeon's nails and hands should be rendered clean.
Antiseptics had brought us to a knowledge of the necessity of
cleanliness, and were adjuvants of cleanliness; so far as they
assisted in securing cleanliness were they useful, and per-
haps not much further than that. But those who were ridi-
culing antiseptics he thought were doing harm, for their
j followers might adopt less efficient methods of cleanliness than
they did.
A Krackowizer Prize.— A communication looking to the
establishment of a Krackowizer prize was referred to the Coun-
cil with power. A resolution was also adopted authorizing the
president to appoint a committee to take into consideration the
advisability of certain changes of, or additions to, the constitu-
tion and by-laws.
NEW YORK CLINICAL SOCIETY.
Meeting of April 24, 1885.
The President, Dr. A. A. Smith, in the Chair;
Dr. Francis H. Markoe, Secretary.
The Treatment of Certain Fractures of the Bones of
the Leg, and of the Patella, hy Drilling and Wiring of
the Fragments. — Dr. J. Williston Wright read a paper on
this subject (see page 477), and showed several of the patients
whose cases were mentioned in the paper. He also read the
history of another case, prepared by Dr. Lerot W. Hubbard
(see page 479).
Dr. V. P. Gibney commended the results. He was particu
larly astonished at the case of patella fracture shown. He
thought that if simple fractures were oftener treated in this
way there would be fewer cases which proved a disgrace to the
profession — the increasing separation in time often rendering
the limbs almost useless. He felt sure that with rigid antiseptic
precautions there was little danger.
Dr. L. B. Bangs remarked that the paper had proved par-
ticularly interesting to him in view of a case which had lately
come under his notice — one of compound fracture of the thigh
in its upper third. The patient came under his care some days
after the receipt of the injury, and when he saw it the frag-
ments could not be replaced in position and the wounds were
in a septic condition. He believed that, if the wire suture had
been used early in this case, both the limb and the life of the
patient might have been saved.
Dr. F. H. Markoe agreed with Dr. Gibney in believing that
the unfortunate result which sometimes occurred after the most
careful treatment of simple fractures of the patella might be
averted by this method, but did not believe that in the present
state of antiseptic surgery it should be adopted in all cases. It
seemed to him that it must be particularly useful in cases in
which there were well-marked obstacles to the putting of the
fragments in apposition, as, for example, clots, etc., in which
aspiration proved of no assistance.
Acute Phosphorus Poisoning.— Dr. E. G. Janewat re-
ported a case as follows :
J. F. D., colored, aged twenty -five, United States, a waiter,
was admitted to Ward 18 (Bellevue Hospital) April 9th, at 6 p.
m. He was, from all external appearances, well, his pulse being
full and regular, and his temperature in the mouth 98° F. He
said he had taken, the evening before, | j of bromide of potas-
sium, having had a great deal of domestic trouble, and not
having slept for a week. This gave him no sleep and produced
no toxic symptoms. He confessed also that at eight o'clock the
same evening he had taken the tops of three boxes of blue-
topped matches, being influenced to do so by having read the
account of a suicide by the same means. He was given an
emulsion of magnesia and oil of turpentine, and his stomach
was washed out with four quarts of water. He vomited out
the tube and the remainder of the stomach contents, which
smelled strongly of phosphorus, and in which were plainly
seen the tops of matches.
April 10th, 8 a. m. — Temperature 99°, pulse 84 and irregu-
lar; complains of nothing but soreness in the back. During
the night he had two diarrhoea] movements.
10th, 12 m. — Temperature 98-75°, pulse 84, respiration 20;
pulse intermittent. Was ordered whisky, § ss. 3ia qu. h., and
put on the use of liquid diet (milk and lime-water). 4 p. m. —
Temperature 98°, pulse 90 and good. The urine was examined,
and found of a reddish-yellow color, of acid reaction, and of a
specific gravity of l-030. It contained a trace of albumin, no
casts, but amorphous urates. He had two scanty diarrhival
movements, containing little fajces.
500
REPORTS ON THE PROGRESS OF MEDICINE.
[N. Y. Mkd. Jon;.,
11th, 4 p. m. — Temperature 99, pulse 72, respiration 25. In-
halations of oxygen-gas were ordered, of five minutes1 duration,
every half-hour during the day. He slept well during the night.
12th. — Complains of general weakness, and soreness in the
back persists. The urine has been examined repeatedly, but no
blood or casts have been found.
Hth. — Doing well. The cornese show slightjaundice.
16th. — Since the 11th inst. the temperature has ranged be-
tween 98° (morning) and 99° (evening). The pulse is good. He
was allowed to get up, and the inhalations of oxygen were
stopped.
He was discharged cured on the 20th.
The President remarked that for some years past he had
taught the use of oxygen-gas in the treatment of acute phos-
phorus poisoning, but could not recall his authority for so
teaching.
Dr. Janeway mentioned that, so far as he could ascertain, it
was not recommended in any of the ordinary text-books.
gc ports on % progress of Ittetrttwe.
GYNAECOLOGY.
By ANDREW F. CURRIER, M. D.
Vicarious Menstruation and Menstrual Exanthemata. — Heitz-
mann (" Med. Jahrb.") remarks that by the term vicarious menstruation
is meant the periodically recurring haemorrhages from any portion of
the body which recur at equal or nearly equal intervals of time, alone
or in connection with menstruation. Such haemorrhages may occur
from mucous membranes (aside from the mucous membrane of the
genital tract), or from or under the skin. Instances are related in
which the bleeding has appertained to the bronchi, stomach, intestines,
nasal mucous membrane, upper or lower extremities, cheeks, etc. In
some cases pathological processes in different parts of the body have
been associated with the phenomena. Within the last few years, espe-
cially since the publications of Leopold upon this subject in 1883, opin-
ions have changed regarding the necessary interdependence of ovula-
tion and menstruation. Many cases are on record in which menstrua-
tion has persisted after both ovaries were removed, and this with other
facts compels us to look beyond the activity of the ovaries, or, at least,
beyond the activity of the ovaries solely, for the cause of menstruation.
The modern physiological explanation of normal menstruation is that
it is an exudation of blood and blood-corpuscles, partly through the
intact walls of the turgescent capillaries of the uterine mucous mem-
brane, partly as a true hasmorrhage through the ruptured vessel walls
which is favored by the construction of the mucous membrane and the
falling off of its epithelial covering. The recent literature of this sub-
ject has been furnished by Leopold, Kundrat and Engelmann, Williams
(J.), Wyder, Ruge (C), and Moricke. The cause for the periodicity of
menstruation has not yet been ascertained. The congestion which ac-
companies this function is not limited to the genital organs, and in this
fact is a partial explanation of the occurrence of vicarious menstrua-
tion ; at least it explains its possibility. Menstruation, whether it be
normal or vicarious, is an evidence, too, of sexual maturity, and in this
particular is to be distinguished from the ha3morrhages which occur
before and after menstrual life, most of which, though they may proceed
from the genital organs, are not connected with the monthly flow. The
theory concerning the meaning and purpose of menstruation which
seems most plausible to the author, though not entirely satisfactory, is
that of Sigismund. This theory maintains that the uterus is prepared
before the menstrual period for the presence and development of the
ovum by the presence of the decidua. If the ovum is not fructified,
there is no occasion for the nourishing function of the decidua, and it
is cast off together with the ovum, menstruation thus being a kind of
abortion. Now, regarding vicarious menstruation, in all the cases
which were investigated by the author, abnormities or diseases were
found in some portion of the genital tract as an explanation of the un-
usual haemorrhage. Smallness of the uterus was especially noticed in
this connection. Cases are quoted in which haemorrhage occurred from
the lungs, nose, stomach, nipples, scars, etc. As the time approached
when the menses would naturally occur, haemoptysis or haematemesis
affected some of the individuals, while with others a swelling of some
kind or other would be manifest, from which blood or bloody pus
would be discharged for a few days, after which there would be a
normal condition until the end of another month. Yet other cases are
related in which with uteri of very small size there were scanty men-
struation and a petechial eruption upon the skin. When the menses
became normal the exanthem and other evidences of congestion dis-
appeared, the locus minoris resistentice having been again established
in its proper seat. From the cutaneous phenomena is deduced the
natural inference that a reciprocal relation exists between the female
genital organs and the skin, and the vicarious office of the latter is
neither unwarranted nor infrequent. The performance of the same
office by other parts of the body is, to a greater extent, exceptional.
Endometritis Dissecans. — Dr. P. Kubas3on (" Ztschr. f. Geburtsh.
u. Gynak.," ix, 2) states, as the result of an analytical study of several
preparations obtained during the past few years from patients with this
disease, that the pathological process is an exfoliative imflammation of
the inner layers of uterine tissue, involving not only a removal of the
entire mucous membrane, but also of the contiguous bundles of muscu-
lar tissue. He finds in all literature only two cases recorded of a simi-
lar disease, and those were described by Siromjatnikoff, in the Russian
language, in 1880. In one of his cases the patient died, and the uterus
was carefully studied. The result was confirmatory of his opinions con-
cerning the nature of the disease, and showed that the exfoliations were
not a product of abortion or of membranous dysraenorrhoea. In each
case the exfoliation occurred at or near the menstrua] period. The part
which was thrown off was three-cornered, had three openings, and in-
cluded mucous membrane and uterine muscular tissue. With it there
was also a discharge of blood, pus, and mucus. The patients showed
some elevation of temperature at the time, which dropped to normal
and was followed by recovery in two of the cases ; in the third it be-
came sub-normal and was followed by death. The process which re-
sulted in this loss of substance was partly phlegmonous and partly
haemorrhagic. The study of these specimens has convinced the author
that the disease is not so rare as might be supposed. The difficulty in
obtaining the discharges of women will prevent such an investigation of
the subject as would be desirable. Turning again to the process by
which the exfoliation is accomplished, the author remarks its similarity
to the process which often obtains in scurvy. Severe haemorrhages
during the process are not likely to occur, on account of the thrombi
which, evidently, are quickly formed in the divided vessels. The mu-
cous membrane may be regenerated from the small islands of that tis-
sue which are left when the main portion is swept away. The causes
of this affection are both predisposing and constitutional, but our im-
perfect knowledge of the subject prevents greater definiteness. The
symptoms noted, in addition to rise of temperature, were vomiting,
diarrhoea, dysuria, lessening of the heart's activity, acceleration of the
respiration, etc., and also others which were directly referable to the
pelvic organs, bearing-down pains, pains in the sides, and the mixed
discharge alluded to. The prognosis can not always be favorable, espe-
cially if the Fallopian tubes are involved. Such a complication proved
fatal in the third of the author's cases. In the way of treatment, the
general health must be brought to as high a standard as possible, and
locally such means must be used as are helpful in relieving uterine
congestion [which the author seems to consider the principal element,
or one of the principal elements, of disturbance]. Chief of these is
the abstraction of blood by scarification or leeching. Narcotics and
poultices will be required should the pain be severe.
The Significance of Alterations in the Kidney which follow the
Development of Fibroid Tumors of the Uterus, with reference to the
Indications for and the Prognosis of Hysterotomy. — Pozzi (" Ann. de
gyn.") summarizes his paper in the following conclusions. 1. Com-
pression of the bladder and the ureters is a complication which is fre-
quent with fibroid tumors of the uterus, even with those which are
moderate in size. It may involve, and with rapid progress, grave altera-
Oct. 31, 1885.]
REPORTS ON THE PROGRESS OF MEDICINE.
501
tions in the kidneys, such as hydronephrosis, cysts, sclerosis, and fatty
degeneration. 2. When this compression is exerted upon the bladder
its effect is readily recognized, but the same is not true when the ureters
are encroached upon, and a positive lesion can not always be diagnosti-
cated until albuminuria has supervened. 3. Compression of the blad-
der or ureters ought to have great weight among the indications for
operation, and may, of itself, determine active interference on the part
of the surgeon. 4. When hydronephrosis exists, the indication for
operation is an urgent one, especially in view of the danger which
threatens the unaffected (or presumably unaffected) kidney. In cases
of this character hysterotomy should first be performed, and when the
patient has recovered from that operation the cyst may be attacked. 6.
The prognosis of hysterotomy is grave, according as the analysis of the
urine indicates renal disturbance. If Bright's disease is clearly estab-
lished it would be a positive contra-indication to the operation, but a
slight degree of albuminuria would not be a contra-indication.
The Statistics of Uterine Cancer and its Operative Treatment. —
Hofmeier ("Ztschr. f. Geburtsh. u. Gynak.") states that a new era in
the operative treatment of uterine cancer began with the announcement
of Freund's operation. Ruge and Veit have studied and published the
account of the pathological anatomy pertaining to the subject. The
question recurs continually, Have the results which have been obtained
repaid the time and labor which have been expended. The statistics of
this paper were gathered mainly from the records of Schroder's poli-
clinic and his private practice. From the former, of 1 8,000 cases, 603
were cases of uterine cancer. From the latter, of 9,400 cases, 209
were of uterine cancer, respectively 3-6 per cent, and 2'18 per cent.
The great preponderance of cases in public over those in private prac-
tice is noteworthy, and is attributed by Schroder to the severer experi-
ence of the poorer classes in the struggle for existence. The age of the
patients in the collated cases varied between 20 and 85, no cases being
presented under 20 :
From 20 to 29 years of age there were 16 cases.
" 30 to 39 " " " 195 "
" 40 to 49 " " " 272 "
" 50 to 59 " " " 192 "
" 60 to 69 " " " 65 "
w 70 to 79 " " " 7 «
" 80 to 85 " " there was 1 case.
In only 39 of these cases were the patients nulliparous, and the rule
was, as has been enunciated by Gusserow, the greater the number of
children, the greater the predisposition to cancer. Of the individuals
referred to in the foregoing table, 76 had borne 10 or more children
each. It was observed that the puerperal period is especially favorable
to the rapid development of the disease. Of the entire number of
cases studied, in 236 there was cancer of the (1) portio vaginalis, in 181
it affected the (2) cervix [i. e., the supra-vaginal portion of it], in 28 the
(3) body was involved, and in the remaining 367 the variety is not
specified. The average age of those who are included in the first
variety was 42, of those in the second 47, of those in the third 54 5.
The average number of children borne by those who are included in
the first variety was 6 ; 7 of them were nulliparae, 33 were primiparse.
The age of the youngest in this group was 26, that of the oldest was
63. In the second variety the average number of children was 6-5 ; in
4 of the cases the patients were nulliparous, in 23 they were primipa-
rous. The disease in this (2) variety came late in life, in many cases,
frequently long after the menopause. Of the third variety 21 per cent,
were nulliparous ; the average number of children was 3-6. No indi-
vidual was operated upon until after a thorough examination under
anaesthesia had been made, and no hope of permanent recovery was
held out in cases in which the uterus was fixed, or the folds of Doug-
las's cul-de-sac and the tissue surrounding the cervix were involved.
The magnitude of the operation (i. e., whether complete or partial extir-
pation) was limited mainly by the variety of the disease. In 160 cases
operations were performed in the hope of obtaining a radical cure.
The prognosis of ultimate recovery was least hopeful in those cases in
which the cervical mucous membrane was affected, since the probabili-
ties were strongly in favor of the disease being extensively diffused at
the same time. This was especially true in old women. In 96 of the 1
cases in which the portio vaginalis was involved, vaginal or supra-vagi-
nal amputation was performed ; in 8 the uterus was extirpated in toto,
per vaginam. Of the 39 cases of cancer of the cervix (supra-vaginal,
or cervical mucous membrane), in 9 supra-vaginal amputation was per-
formed, and in 30 the entire uterus was removed, 6 of the latter opera-
tions being by Freund's method. In 17 instances operations were per-
formed for cancer or sarcoma of the body of the uterus, 13 of them
consisting in the abdominal supra-vaginal amputation, and 4 in total
extirpation of the uterus ; two of the latter operations were after
Freund's method. Of the 160 cases operated upon, 31, or 19 per cent.,
were fatal — 20 from septic infectious processes, within a few days, 8
from haemorrhage, in most cases within a few hours after operation, 1
from trismus, 1 from shock after Freund's operation, and 1 from iodo-
form poisoning. Of the vaginal and supra-vaginal (cervical) amputa-
tions 12-3 per cent, resulted fatally. Of the vaginal and supra-vaginal
(by abdominal section) total extirpations 26 per cent, of the former and
30 per cent, of the latter resulted fatally. Of the Freund operations 62
per cent, were fatal. Of the 17 cases of cancer of the body of the
uterus in which operations were performed, 6 were fatal from the im-
mediate effects of the operation, in 4 the ultimate result was not ascer-
tained, in 3 others a fatal issue from recurrence of the disease occurred
within a year, and in the remaining 4 there had been no recurrence dur-
ing periods ranging from two to five years. In the 19 cases of total
extirpation the operation was too recent for any judgment as to its
ultimate value in 2 of them, in 5 the disease recurred within six months,
in the remaining 12 only 2 were quite free from recurrence after three
years. In 7 cases of cancer of the cervical mucous membrane the
supra-vaginal amputation (per vaginam) was performed, and only two
of the patients were free from recurrent disease at the end of two years.
In 96 cases of cancer of the portio vaginalis, vaginal or supra-vaginal
amputation was performed, 85 of the patients surviving the operation.
At the end of three years 12 of these 85 were known to be entirely
well ; concerning several no report was obtainable ; all the others had
suffered recurrence. The uterus was entirely removed per vaginam in
8 instances for disease of the portio vaginalis, 7 of the patients recover-
ing. At the end of fourteen months only 1 of the 7 was known to be
well. Of 129 successful operations of all kinds, there had been no
recurrence after two years in 28 cases — that is, 21-8 per cent. In four
of these, however, the disease recurred at periods varying from two
years and a half to three years and a half. Notwithstanding these
unfavorable facts, the author believes that an extension of life for two
years is ample justification for the risks of a capital operation. The
most favorable prospects for radical cure are thought to be offered by
an operation which shall consist of excision plus the use of the actual
cautery. In comparison with this method of operation Schroder does
not think favorably of the galvano-cautery wire. As a summary, the
results which have been set forth by these statistics, though not so
favorable as could be desired, furnish a justification, in the opinion of
the author, for a continuance of operative measures.
Nephritis consecutive to Epithelioma of the Uterus. — Lancereaux
(" Annales des mal. des organes gen.-uriu.") boldly advances the propo-
sition, which he thinks is justified by his experience, that in every case
of epithelioma of the neck of the uterus there is, at some time, nephri-
tis existing as a complication. This lesion is distinct from primitive
interstitial nephritis, and is not, like that, accompanied by hypertrophy
of the heart. Twenty-three cases are detailed to substantiate his propo-
sition, these being cases which could be thoroughly investigated post
mortem. Three varieties of epithelioma may affect the uterus, or, in
other words, as many varieties as there are varieties of epithelium in
connection with the uterus. That which is developed from pavement
epithelium is the most common form, and may begin either from the
vaginal cul-desac or from the lips of the vaginal portion of the cervix.
h is this variety also which, on account of its situation, predisposes
more than any other to degenerative changes in the urinary passages
and the kidneys, and it is the sole variety to which the author refers in
this paper. Its progress is marked by ulceration, with its accompany-
ing foetid, sanious discharge, and by the characteristic indurated con-
dition of the tissue of the vaginal portion of the cervix. The haemor-
rhages which accompany its development are, in some cases, so severe
as to lead to a fatal issue before the kidnevs have become involved
502
REPORTS ON THE PROGRESS OF MEDICINE.
[N. Y. Med. Jour.,
such cases being, of course, exceptions to those which are laid down in
the author's general proposition. Notable features of the disease, also,
are severe pain, especially along the course of the lumbar and sciatic
nerves, disordered digestion and nutrition, and various troubles in con"
nection with the urinary passages. Urination becomes frequent and
painful, and may be accompanied or followed by spasms. The urine
may be bloody, and under the microscope may reveal epithelial cells, leu-
cocytes, and crystals of various kinds. At other times it may be clear,
pale, and abundant. In still other cases it may be purulent. Its solid
constituents are very apt to be diminished. In the larger portion of
the author's cases albuminuria was present, and uraemia, more or less
intense, was so common that it was regarded as the rule. The form
■was that which affects the alimentary canal, being manifested by loss
of appetite, vomiting, and diarrhoea. Less frequently uraemia, with
cerebral manifestations, was present, being manifested by headache,
insomnia, delirium, or coma. Uraemia accompanied by dyspnoea was
rarely seen. Uraemia, in some form or other, is assumed to be, habitu-
ally, the cause of death, if that event is not attributable to some acci-
dent, or to a complication. The propagation of this disease seems to
be, in the majority of cases, in the direction of the bladder rather than
that of the rectum. It is brought about by means of the epithelial
traces which lead to the formation of an embryonal connective tissue in
the midst of the tissue which unites the bladder with the upper part of
the vagina and the cervix uteri. Next epithelial elements appear in
this tissue, which, as they develop, compress and produce atrophy of
the muscular fasciculi, and form nodosities which project toward the
basfond of the bladder and along the course of the ureters. The re-
sulting ulceration leads to vesico-vaginal fistula. The ureters, surrounded
by the epithelial growth, become nearly occluded at the point of ob-
struction. Above that point they become dilated by the retained urine,
as well as the pelves and calices of the kidneys, the Malpighian bodies
become atrophied to a greater or less extent — in a word, there is a con-
dition of hydronephrosis. After a primary enlargement of the kidneys
there follows a diminution in size. The capsule may be easily removed,
revealing the free surface of the organ smooth, yellowish, and without
granulations. The cortical substance is thin, firm, and yellowish upon
section. The pyramids are small, indurated, and sometimes atrophied.
Microscopical examination shows that the lesion of the kidney, in cases
of this character, is a diffuse sclerosis, and, in the author's experience,
it was most pronounced at the summit of the Malpighian bodies, the
uriniferous tubes being here separated by bands of embryonal tissue
and the tubes themselves being more or less atrophied. At the middle
and base of the Malpighian bodies the process was found to be less in-
tense. The cortical substance is involved in this process, the glomeruli
and the convoluted tubules of the periphery being chiefly implicated.
In many of the tubules the epithelium has disappeared, in others it is
only disarranged. These are the principal characteristics of nephritis
which is consecutive to uterine epithelioma. The disorders which fol-
low the imperfect performance of its functions by the kidney are prin-
cipally those which have reference to the alimentary canal.
On the Treatment of Uterine Cancer ; Advantages of Amputation
of the Neck of the Womb with the Galvanic Wire Gallard (" Ann.
de gyn.") urges the propriety of giving more attention to what are ap-
parently hopeless cases of disease, referring especially to uterine can-
cer. He has tried the plan of injecting, with caustic fluids, diseased
tissues and those which are immediately contiguous to them in the
hope of staying the progress of the disease, but no lasting benefit has
resulted ; indeed, he thinks such measures are oftener harmful than
useful. Cauterization with iron at red heat has given good results in a
certain number of cases, but it is believed that the simple burning of
the diseased foci is not sufficiently radical in such a disease as cancer
of the uterus. The serre-noeud of Maisonneuve and the ecraseur fur-
nish more thorough means for operation than any of the foregoing, but
they have certain disadvantages, among which may be mentioned diffi-
culty of adjustment and liability of the wire either to slip or break.
With the galvanic wire adjustment is easier, for only a fine wire is re-
quired, and this can be guided by the fingers to the desired point, and
kept in position during the operation without much trouble. The elec-
tric current having been established, the cervix, grasped with hook-
forceps, is to be drawn slowly downward until the uterine tissue is cut
through. The author does not deny that the same accidents may occur
with the cautery-loop which frequently happen with the serre-nceud or
the 6craseur, and in some cases it has been necessary to abandon the
use of the former and complete the operation with one of the latter in-
struments. Twenty-five cases have been operated upon by the author,
in which more or less complete histories have been taken. Twelve of
these have, it is thought, been cured. In three of them the time which
has elapsed since the operation is, respectively, eighteen months, two and
a half years, and nearly four years, and no trace of the disease is dis-
coverable. Even should the disease return after the operation with the
galvanic loop, its progress seems to be less rapid than when a cutting
instrument has been used, probably because of some modification which
the tissues have undergone as the result of the operation. Accidents
following the operation are very rare, occasional haemorrhages having
been observed. There is some pain, but not so severe as in some
classes of burns, and it may readily be relieved. The patient should
remain in bed for about three weeks, during which time there should
be no examination* or treatment, unless it is imperatively demanded.
Total Extirpation of the Uterus by the Vagina. — Demous (" Rev.
de chirurgie ") remarks that extirpation of the uterus is one of the
operations which have been considered unjustifiable by many surgeons,
and that there are some who so consider it even at the present time.
Of ancient origin, it was for a long time discarded, to be revived, like
many others , as the fruit of antiseptic surgery. Especially in cases of
cancer of the uterus does it hold out the single chance of relief from
that dreaded and dreadful disease, but it is also worthy of consideration
in any chronic disease of the uterus (1) when that disease threatens the
patient's life ; (2) if there is a certainty that no other operation holds
out any chance of recovery ; (3) if complete removal of the diseased
parts can be accomplished without wounding neighboring organs ; (4) if
no other fatal disease complicates and contra-indicates the operation.
A large, rigid, and unyielding uterus and a small vagina would be effect-
ual contra-indications to the performance of the operation. When
operation has been decided upon, in a given case, the following plan of
treatment is suggested by the author as appropriate : Rest for a num-
ber of days preceding the operation, especially if the patient is subject
to haemorrhages; hot vaginal injections of carbolized water, during
the same period, frequently repeated ; a cathartic on the evening of
the day preceding the operation, and a rectal injection the following
morning. The operation should be performed in a well-lighted and
ventilated room, with an even and mild temperature. After the patient
has been placed in the lithotomy position, the hair should be shaved
from the genitals ; the vagina, vulva, and contiguous parts should be
disinfected with carbolized water of the strength of 30 to 1,000. The
bladder should be evacuated, and, at one's option, an application of
chloride of zinc may be applied to the cervix. The last-mentioned rec-
ommendation is both for purposes of antisepsis and to diminish the
probabilities of haemorrhage. Next, the walls of the vagina are sepa-
rated widely with retractors, the cervix is seized with a volsella and
drawn downward and forward as far as possible, and a circular
incision of the vagina is made with a straight bistoury at a suffi-
cient distance from the uterus to include healthy tissue, if that is
possible. The further separation of the cervix from its surrounding
tissues should be made by tearing with the finger, if the tissue is not so
firm that a cutting instrument is required. The close proximity of the
bladder, and the danger of wounding it, must be borne in mind, as the
dissection is continued until the anterior peritoneal cul-de-sac is opened.
This opening must be extended until the uterus is freed from its at-
tachments anteriorly, after which the organ is to be completely retro-
verted, either by the fingers passed into the anterior opening, or by
instrumental means. The most difficult part of the operation follows,
namely, the ligation and division of the broad ligaments. Catgut liga-
tures are preferred by the author (No. 1 for the first ligature on each
broad ligament, No. 2 or No. 3 for the others), and they are to be
passed by means of a long, curved needle fixed in a handle, and pierced
near its point. The first ligature includes the upper third of the broad
ligament, the round ligament, and the Fallopian tube. The latter is not
to be penetrated by the needle. The second includes the middle third
of the broad ligament, and the third its lower third ; the latter also in-
cludes the trunk of the uterine artery. These ligatures must be passed
Oct. 31, 1885.]
MISCELLANY.
503
as far from the uterus as possible, in order to include healthy tissue,
and must be tied firmly and with unusual care. The uterus should
then be cut away from the broad ligament which has thus been secured,
and the same procedure adopted with the remaining broad ligament.
The ovaries are not to be removed. Haamorrhage from small vessels is
not usually abundant, but it is better to tie them whenever they are
cut. Various modifications of this operation (which is attributed to
Recamier) have been suggested by different surgeons for the purpose
of facilitating the removal of the organ and giving greater security
against haemorrhage. The possible accidents of the operation are the
wounding of the bladder or the ureters, in addition to the possibility of
haemorrhage, which is ever present. The shock experienced by the
patient is usually not severe, and not to be compared with the shock
which attends hysterectomy by abdominal section. After the removal
of the organ the wound of the vagina may be left open (and the author
thinks this a bad and a dangerous plan), or the edges of the wound may
be brought together, a suitable opening being left for drainage. This
means is all-important in this operation — far more so than in most cases
of ovariotomy. The suturing of the peritonaeum is neither recom-
mended nor disapproved, the author frankly admitting his want of ex-
perience in this direction. The vagina is to be packed with iodoform
gauze, or with salieylated cotton. This should be removed upon the
second day, or sooner if the discharge is abundant, and should be re-
newed sufficiently often to insure healthy surroundings to the wound.
The use of frequent vaginal injections is not approved. Sanger's sta-
tistics, published in 1888, show one hundred and forty-three operations,
of which one hundred and thirty-three were for cancer, six for prolapsus
uteri, and four for fibromata uteri. In one hundred and three cases
the operation was successful, the patients recovering, at least for a
time. The time varies from a few weeks to an indefinite period. In
fact, reliable statistics can not as yet be made. Schroder, Martin,
Lomer, and von Teuffel have had cases in which there was no recur-
rence after a year and a half or two years from the time of the opera-
tion. As a further element in favor of the operation, should recur-
rence take place, the symptoms which accompany it are not likely to
be so severe as those which accompany the primary disease. As to the
mutilation which is caused by the operation, the author asks if it can
be considered greater than that which follows operation for cancer of
the tongue, oesophagus, or rectum.
Uttsrjellang .
The Present Status of the Affairs of the Congress. — The "Mary-
land Medical Journal " says : "The new committee on the reorganiza-
tion of the Congress, which held its meeting in New York on Septem-
ber 3d to 'lepair the damages' occasioned by the resignations of the
gentlemen appointed by the first committee, does not seem to have met
with such marked success as its offieial organ, the ' Journal of the
American Medical Association,' predicted for it. Indeed, so far from
having repaired the damages previously inflicted upon the Congress by
its Chicago work, this committee has made blunder after blunder until
its action has become ridiculous in the eyes of the entire profession
throughout this country and Europe. Its mistakes have been so glar-
ing and faulty that one of its own number has been forced to show that
its affairs have been conducted in the interest of its own officers, and
that its deliberations have been so suppressed and manipulated that the
reports of its meeting in New York were not in keeping with the facts.
" The committee has added another insult to the list of injuries pre-
viously perpetrated by its arbitrary assumption of authority. Through
its Executive Committee it has formally declared that its acts are ' not
subject to revision, amendment, or alteration by either the Committee
of Arrangement or the American Medical Association.' In fact, it
usurps all power and resolves to run the Congress according to its own
methods. The result of this singular and unjustifiable procedure be-
gins to be apparent. Within the last ten days a number of the ap-
pointees of the New York meeting have declined to accept the positions
to which they were assigned. Such gentlemen as John C. Dalton, Hen-
ry I. Bowditch, Henry F. Campbell, Robert Battey, E. 0. Shakespeare,
and others have been forced to desert the sinking fortunes of an organi-
zation which has done nothing but trifle with the best interests of
American medicine since it came into existence.
"Some weeks ago, in discussing the outlook for the Congress, we
urged the present committee to resign, and gave, as we believed, satis-
factory reasons for this advice. The resignation of this committee
would have been a graceful act and would have saved the profession in
this country from the mire of contention into which it has been cast by
the unwarranted action of the association at New Orleans. The com-
mittee, however, saw proper to lay aside all considerations for the in-
terests of the profession and entered upon the work of reorganization
of the Congress in a manner agreeable to its membership. This com-
mittee has no one to censure but its own membership, if its action has
failed to give entire satisfaction to the profession. It has proceeded
with its work in the face of active and outspoken criticism, and it must
stand or fall accordingly. We have believed that the work it was at-
tempting to do was wholly unnecessary, and we have advocated its
abandonment of this work on the ground that its continuation would
promote nothing but strife and dissensions. We have never believed
that the success of the Congress could be promoted by its interference.
On the contrary, we have predicted that the Congress would fail if
intrusted to its efforts. This prediction we believe will be shortly veri-
fied. The work of disorganization has continued, the breach has been
made wider, and the affairs of the Congress are in a more pitiable plight
now than at any previous time. If this committee now fails to see the
handwriting on the wall which significantly tells of its downfall, we are
at a loss to account for its stupidity and want of comprehension. Its
continued effort to carry out thL: work of reorganization only increases
the depth of its mortification and chagrin at its final overthrow. We
would again suggest to this committee the advisability of gracefully
stepping down from its present lofty but absurd and arrogant posi-
tion."
In another article, the same journal says : " The present Secretary-
General of the Congress has had nothing good to say of those gentle-
men constituting the original Committee of Eight on the Organization
of the Congress for having accepted positions in the various offices of
their own appointment. How can the Secretary-General reconcile his
own position in this respect ? Virtually the American Medical Associ-
ation and the International Congress are combined in his august person.
He is more autocratic than the Czar of Russia."
A Philadelphia View of the Congress Organization. — The " Jour-
nal of the American Medical Association " publishes the following, in
a letter from its Philadelphia correspondent, " C. W. D." :
" The questions in regard to the proposed meeting of the Inter-
national Medical Coagress, which were the subject of so much discus-
sion when I last wrote, have ceased to be a live issue in this city. The
action of the new committee in New York seems to leave nothing to
be done but to wait and see whether the European men will come to
America under the circumstances or not. It is believed here that they
wdl not, at least not in sufficient numbers to give the meeting an in-
ternational character. It is also thought by some, and hoped by others,
who did not approve of all the acts of the original committee, that
those who have charge of the interests of the Congress in Europe will
decide to hold the next meeting in some city there — Berlin is spoken of
as most likely. This, as one of the most conservative men in this city
said to me a few days ago, would be the simplest way out of an awk-
ward dilemma, and would furnish an opportunity for the present ex-
citement of feeling to subside to the advantage of all concerned.
" I have heard some comment upon the action of the new Execu-
tive Committee in New York on September 24th, whereby they unani-
mously resolved that what they were to do was not subject to ' revision,
amendment, or alteration' by the General Committee, which appointed
them, or even by the American Medical Association itself. It is won-
dered here whether such a declaration of independence will be tolerated
by the association when it meets in St. Louis, or whether it will send
the committee out to read and reflect upon the opinion of Mr. Randall
with which their predecessors were put to naught. Time alone can
504
MISCELLANY.
[N. Y. Mkd. Jocr.
show ; but the members of the original committee are said to feel a
keen regret that they did not at the start adopt this easy method ' to
prevent all further misunderstanding, both at home and abroad.' "
The False Position of the Committee of the American Medical
Association resolutely adhered to. — Under this heading the " North
Carolina Medical .Journal" says:
" Discussion, so far, has done little to stay the ruinous course pur-
sued by the malcontents of the New Orleans meeting in regard to the
International Congress. The new combinations of the Chicago and
New York committee meetings have only made a bad matter worse.
When we look back upon the whole affair from this standpoint, we
can not help feeling that those gentlemen who represented the Inter-
national Medical Congress made a very unwise move in asking the
American Medical Association to take any part in the construction of
the forthcoming meeting. These gentlemen would have done far bet-
ter by taking the whole responsibility upon themselves, and this course
would have been satisfactory to the members of the last Congress, the
evidence of which we have in Sir James Paget's letter to Dr. Hays.
The discourtesy of the American Medical Association toward the origi-
nal committee seems not to occur to the reconstruction committee, and
there can be but one interpretation of the whole matter — the new com-
mittee intends to organize a Congress upon a basis so objectionable that
it has already divided the profession into two parties. If the gentle-
men composing this new organization are willing to undertake it, they
can not be prevented, but it would be well if they could be, both for
the success of the Congress and the unity of the profession. We have
written the above lest by silence it might be thought that this journal
has altered its views upon the subject. The American Medical Associa-
tion has made a false step, and it will be exceedingly fortunate if it re-
covers from it without estranging some of its most desirable mem-
bers."
THERAPEUTICAL NOTES.
The Juice of the Fig-tree as a Digestive. — Signor Bianchi, of Flor-
ence (" Semaine med." ; " Lyon med."), has ascertained that a drop or
two of the juice of the leaves, or of the unripe fruit, will rapidly reduce
a bit of fibrin to a bouillie soluble in water and giving the reaction of
the peptones. This new agent is therefore likely to be of service in
cases of dyspepsia due to defective secretion of the gastric juice. It
should also be capable of taking the place of papain as an application
to diphtheritic membranes and ulcers.
An Injection for Paralysis of the Bladder. — The " Union m6dicale"
credits the following formula to Dumreicher :
Extract of nux vomica 3 to 6 grains;
Distilled water 6 ounces.
One sixth of the whole is to be injected into the bladder every day,
and retained for an hour. At the same time, electricity may be used
with advantage, and micturition is to be regulated as much as possible
the urine being passed every four hours.
The Treatment of Inflammation of the Vagina. — According to the
same journal, M. de Sinety recommends the following liniment :
Subnitrate of bismuth 90 grains ;
Crystallized carbolic acid 15 "
Glycerin 6 drachms ;
Distilled water 3 ounces.
Cotton tampons soaked in the mixture are to be introduced into the
vagina. They may likewise be moistened with coal-tar or covered with
the following ointment :
Pyrogallic acid 150 grains ;
Starch 225 "
Vaseline 1$ ounce.
At least two applications should be made daily, and care should be
taken to carry the tampons to the very top of the vaginal cuh-dc-me.
They must be carefully freed from all excess of either liniment or oint-
ment, as it would run out upon the vulva and create unnecessary pain.
Caustic Crayons. — Moser's formula (Ibid.) is given as follows:
Powdered charcoal 1 ounce;
Nitrate of potassium 1 drachm ;
Porphyrized iron 75 grains;
Benzoin 15 "
Add enough adhesive powder to make forty crayons. These crayons
are hard, light easily, and produce immediate cauterization, so that
they are suitable for the treatment of poisoned wounds.
Direct Interstitial Medication by Dielectrolysis. — M. A. Brondel,
of Algiers, brought forward a novel plan of medication at a recent
meeting of the Paris Academie de rnedecine (" Rev. med."). By the
term dielectrolysis (dielectrolyne) he refers to a process for making a
nascent chemical substance pass through the tissues. For example,
taking iodine, a body which is readily " dielectrolyzable," he applies to
any desired part of the person a compress wet with a solution of iodide
of potassium, and over it he places the negative electrode of a galvanic
battery, the positive electrode being held against any indifferent part of
the body. The iodine leaves the potassium, and, actually traversing the
intervening tissues, rapidly arrives at the positive electrode, as may be
ascertained by testing with starch-paper. In effect, therefoie, this is a
hypodermic, or rather interstitial (inlra-or(janlqut)> method without
wounding the skin or producing pain. As a great number of si i n pie
bodies may thus be made to penetrate from one point to another, the
practical applications of the new method may be very numerous and
very important. By it the author has cured fibrous tumors of the
uterus, a case of perimetritis, a rheumatic ovarian neuralgia, and sev-
eral cases of chronic rheumatism. He has in view further trials upon
parasitic and malignant tumors, diseases of the skin, syphilis, neural-
gias, etc., and especially pulmonary consumption, on which latter he
proposes to try the action of various mineral antiseptics, such as arsenic,
mercury, fluorine, etc.
Cocaine in the Treatment of Hay Fever. — In a paper lately read
before the College of Physicians, of Philadelphia, Professor J. M. Da
Costa said :
" The manner of employing the cocaine is not without importance.
It may be used with a small atomizer as a spray. But the readiest
means is to inject from five to eight drops up each nostril, the head
being thrown backward; in some persons once, in most twice, daily will
be found sufficient. It will be necessary to instruct patients not to
irritate the membrane by rubbing it needlessly with the glass tube, or
pushing this up too far. Thus, a patient who had had hay fever for
thirteen years, and who was at the sea-shore on the 17th of August
when the hay fever came on, and in whom tincture of Ignaiia amara
seemed favorably to influence its course, tried cocaine in one nostril
only. He inserted the tube far up, irritated the membrane, and water
ran from that nostril, which became sorer and more inflamed than the
other. More judicious attempts produced better results, but he could
not be persuaded to give the remedy a fair trial, owing to his first ex-
perience with it. Its mode of action in hay fever is partly by the local
insensibility it produces, partly by the contractions of the capillaries it
induces. The effects are thus chiefly local. It will not arrest the
bronchial catarrh or the asthma which attend some cases ; yet it is
astonishing how it seems to lessen the tendency to these complications
when early applied, and before they have got much headway. Is its
action, then, not partly a reflex action ? That the remedy is radical,
and, strictly speaking, curative, I have not found ; but that it gives
great comfort, converts bad into light cases, enables those to stay at
their homes who otherwise are obliged to flee to hay-fever resorts, re-
lieves much suffering and distress, I know and have fairly tested. In
no case of rose-cold or hay fever ought cocaine to be left untried."
Ethyl Compounds of Mercury. — In view of the present rage for
testing all possible compounds of mercury in regard to their fitness for
hypodermic use, Dr. P. Hepp, of Strassburg, has thought it wise to pub-
lish a sort of warning concerning some of the ethyl derivatives, in the
form of a preliminary note (" Ctrlbl. f. klin. Med."). He has been en-
gaged in studying the properties of ethylmercury and ethylsulphate of
mercury, but he has not yet been able to look upon it as warrantable
to use these dangerous poisons on the human subject, although the
temptation to use them is heightened by the fact that neither an
oily solution of the former nor an aqueous solution of the latter causes
the slightest pain when injected under the skin. He refers to the
sad results to two English chemists from inhaling^ the fumes of methyl-
mercury.
THE KEW YORK MEDICAL JOURNAL, November 7, 1885.
$tttutt» attb ^ fob rf ssss .
A SKETCH OF THE LIFE OF
JAMES LAWRENCE LITTLE, M.D.,
AND OF THE TWENTY-FIVE YEARS IN WHICH HE
PRACTICED SURGERY IN NEW YORK*
By D. B. ST. JOHN ROOSA, M. D., LL. D.
James Lawrence Little was born, of Scotch-Irish and
English ancestry, in the city of Brooklyn, February 19,
1836. He attended private schools in his native city until
he was about twenty years of age, when he attempted to
become a bookseller, and for this purpose became a clerk in
a Fulton Street establishment kept by Mr. Riker. The firm
that engaged him had a stock of medical books as well as
of general literature. The young clerk was soon so deeply
engaged in the study of these books that he proved a very
inefficient salesman, and he soon gave up his attempt in
business. This inclination to the study of medicine had
already been seen in young Little when he was a mere boy.
After much cogitation as to the ways and means of getting
a skull for the purpose of study, he finally approached a
venerable African grave-digger, who consented to furnish
him with the desired relic if he would bring twenty -five
cents and a paper to wrap it in. Young Little secured the
treasure on these terms, and, returning home, took a peep
at- it, and, to his youthful horror, found that it was an un-
prepared skull looking upon him in the ghastly covering of
facial integument and scalp. Fear got the better of his
anatomical enthusiasm, and seeking a plan to get rid of
what was now a source of dread at its horrible aspect, as
well as fear lest he might be found with such an unexplain-
able object upon him, he threw it into the waters of Walla-
bout Bay, and postponed his medical studies for a season.
After leaving the bookstore, Little entered the office of
Dr. Willard Parker as a private student, and at the same
time he matriculated in the College of Physicians and Sur-
geons. After Dr. Little had become a distinguished sur-
geon, Dr. Parker gave the writer an account of how he
nearly rejected him when he applied for entrance to his
already crowded rooms. He was at first disposed to decline
to receive another student, but he was impressed by the
great earnestness of the tall and handsome young man, and
he consented to take another student. " But," continued
Dr. Parker, " I never had occasion to regret my decision.
Punctually as the clock struck nine the click of the young
man's step was heard upon the doorstep, and I got to recog-
nize his step and to count upon him, whoever failed." The
word click aptly describes the short and quick step that
many of Dr. Little's contemporaries will recall as one of his
personal characteristics.
After being in Dr. Parker's office more than two years
he successfully passed a competitive examination, and was
appointed a junior assistant in Bellevue Hospital. This ap-
pointment did not take effect until the following spring.
* Read before the New York Academy of Medicine, November 5,
1886.
Meanwhile, in March, 1860, he was graduated at the College
of Physicians and Surgeons. He then resigned his position
at Bellevue, and after examination he was appointed junior
assistant on one of the surgical divisions of the New York
Hospital. A resignation of a place in one hospital to take
a similar one in another was something unusual, and it was
said at the time that it caused a little unpleasant feeling
among the staff at Bellevue, for Dr. Little was well known
to some of them, and to James R. Wood in particular, as a
promising man whom it was not well to lose.
Bellevue Hospital was just coming into some impor-
tance as a school of surgery, and chiefly through Dr. Wood's
clinics and his prizes for anatomical preparations offered
for competition among the medical schools. Yet at that
time it could in no manner compare with the New York
Hospital in furnishing opportunities to a surgical student.
It was an institution belonging to the city, receiving only
paupers to its wards, and it was governed by politicians.
It had much more importance as a school of medicine than
as one of surgery. Dr. John W. Francis was one of its
consulting physicians, and occasionally gave a mellifluous
and learned address in its amphitheatre, and Alonzo Clark,
John T. Metcalfe, and Benjamin W. McCready held clinics
in the wards, while on Saturdays there was a great crowd
of students to witness the rapid and skillful surgical opera-
tions of the renowned pupil of Valentine Mott, James R.
Wood. Certainly any young doctor in medicine might
have been honored by entrance into such a hospital. But
the New York Hospital was a wealthy and private corpora-
tion, governed by some of the best laymen in the city, and,
more than all, it was one of the most renowned schools of
surgery in the world. In its amphitheatre Wright Post
and Kearney Rodgers had won their fame, and here Valen-
tine Mott, who was still living and lecturing upon surgery,
had tied the arteria innominata. He was consulting surgeon
with Alexander H. Stevens, John C. Cheesman, and Alfred
C. Post. Of these, but one now remains, an honored link
to connect us to the medical New York of fifty years ago.
The active members of the surgical staff were Gurdon Buck,
John Watson, Thaddeus M. Halsted, Willard Parker, Will-
iam H. Van Buren, and Thomas M. Markoe. Of this num-
ber but one now survives, and he happily in full vigor of
mind and body.
The old hospital was beautifully situated on Broadway,
facing Pearl Street, on ample grounds, with grand old elms.
Its beautiful lawn, upon which tame deer might often be
seen, was a surprise and delight to the strangers in New
York, who came suddenly upon this break in the whirl of a
great city. The house staff was in a traditional state of
excellent discipline. Its members vied with one another in
their care of their cases, and their dressings of fractures
and ulcers were at once the delight and dismay of medical
students, who followed the attending surgeons about the
wards. It was not strange, then, that young Little, especially
when urged by his preceptor, resigned his place in a hospital
which had no past for one whose annals, twenty-five years
ago, were more full than perhaps any surgical hospital in
the land.
506
BOOS A: THE LIFE OF JAMES LA WEENCE LITTLE, M. D.
[N. Y Med. Jook.
In April, 1860, Dr. Little began his duties at the New
York Hospital as a junior walker. In April, 1885, lie died.
Hence, it may be truly said that a quarter of a century
bounded his professional career. What a twenty-five years
it has been for medical and surgical science in New York
and in the world ! There were then three colleges and per-
haps eight hundred students and practitioners attending lec-
tures in the College of Physicians and Surgeons in Twenty-
third Street, the University in Fourteenth Street, and the
New York Medical College in Thirteenth Street. Bellevue
Hospital Medical College existed only in the embryo of its
medical clinics and James R. Wood's exploits on Saturday
afternoons. Clinical instruction was in its infancy, and
there were but two hospitals, at long distances from the
colleges, where it may be said to have existed in a meager
way, and then to be attended by not more than a score or
so of the students, except when a great operation was to be
performed. Now there are added to the New YTork and Belle-
vue, the great Charity Hospital on the Island, St. Luke's,
the Roosevelt, the Presbyterian, Mount Sinai, and St. Vin-
cent's ; these are all more or less used for clinical teaching,
and eighteen hundred or more students and physicians at-
tend the lectures of the three colleges of our faith, the Col-
lege for Women, the Post-Graduate School, and the Poly-
clinic. Among the most widely known of the teachers at
the colleges were Parker, Gilman, Watts, St. John, and
Joseph M. Smith, in Twenty-third Street ; John William
Draper, Bedford, Paine, Van Buren, Post, and Metcalfe, at
the University; Horace Green, Fordyce Barker, Ogden Do-
remus, and Carnochan, in the New YTork College ; while
George T. Elliot, Charles A. Budd, Loomis, Jacobi, Thomas,
and Sands were, as would be said in Edinburgh, extra-mural
teachers, who were nearly within the walls. As we recall
many of these names, the words of the Latin poet come at
once to our memory :
" Eheu fugaces posteum posterum,
Labuntur anni."
When Dr. Little entered the New York Hospital the
civil war had not broken out, although exciting meetings of
students had been held on account of the John Brown raid,
and Southern students were being pledged not to return to
Northern cities for instruction. Terrible strife was soon to
cause the erection of immense hospitals by the medical staff
of the P/nited States army, from whose records surgical
literature was to be enriched to an extent not dreamed of
by the surgeons of this country. The battle-fields of Ma-
nassas, Shiloh, Gettysburg, and around Richmond were, from
their awful experiences, to train a race of men which has
caused American surgery and medicine to take a higher
place in the world than would have been attained by half a
century of work in small civil hospitals, while the Sani-
tary Commission was to open up a field for the cultivation
of sanitary science and of active benevolence hitherto un-
known.
When Dr. Little entered the wards of the New Y"ork
Hospital the thermometer was not used to show the tem-
perature of the body. The laryngoscope and ophthalmo-
scope had just been placed in the hands of a very few spe-
cialists, but they were not at all employed in the New York
general hospitals. There was but one hospital of any con-
siderable importance for diseases of the eye and ear, and
that had not one half the number of patients it now has,
although three similar institutions have been added to the
charitable and educational resources of the city. There were
no training-schools for nurses, and scarcely any trained
nurses worthy the name. Those whom we had were chiefly
males, who had been promoted from being patients to be
nurses, with a strong preference for alcohol as a stimulant,
while the women, in many instances, had been scrubbers in
the wards over which they now presided. Not but that
there were some excellent nurses in those days, however.
Pyaemia, erysipelas, and hospital gangrene were then dreaded
foes, and antiseptic surgery, if practiced in attempts at ab-
solute cleanliness, was not understood as now, when pa-
tients, after operations, are saved, not as by fire, but as a
matter of course. Marion Sims was just about to found the
Woman's Hospital and become the intellectual progenitor
of men who with him created modern gynaecology. All
this Dr. Little saw, and in much of it he was an active par-
ticipant.
New York, in 1860, had two or three medical journals,
not of extended circulation, while an Ishmaelitish scribbler
or two issued monthly bulletins in a style of medical jour-
nalism now happily extinct. There were two medical book-
stores, called publishing-houses rather by courtesy than as a
matter of fact, for no New Yorker wrote a medical book,
and very few even edited or translated one. New York
scarcely claimed equal rank with Philadelphia as a medical
center. Now New York boasts three publishing-houses
where American medical books are issued, and that in con-
siderable number. Her medical journals are more widely
circulated than those of any other city in this country, and
they are to be found by the side of the works of American
medical men upon the library -tables of the physicians of
every nation.
In the hospital, Little gave promise of his future career.
He was assiduous and faithful as an assistant, and suggestive
and enthusiastic as a house surgeon. His humorous con-
temporary, Dr. Samuel W. Francis, remarked of him, that
even then there was multum in parvo. He reported many
of the cases occurring in the wards in the " American Medi-
cal Times." It was while in the hospital that he devised
his method of making and applying plaster-of-Paris splints.
It is not too much to say that chiefly, if not entirely,
through Little's efforts plaster-of-Paris splints became a
practical application. Until then, although much recom-
mended, experience had shown that it was not well adapted
for a surgical dressing. Little saw in plaster of Paris a
material which, if properly used, would form that so much
to be desired, an immovable and yet porous splint. Those
of us who were associated with him remember his painstak-
ing trials in preparing the plaster, in securing the proper
consistency, and the material best adapted to take up the
solution ; the disappointments and failures until a splint was
produced which convinced his colleague, the house surgeon
of the other division, and the attending surgeons, that the
days of the starch apparatus, a favorite bandage of the hos-
Nov. 7, 1885.]
ROOSA: THE LIFE OF JAMES LAWRENCE LITTLE, H. D.
507
pital, were past. In using plaster of Paris as a splint in-
stead of a bandage, lie utilized the material as never was
before done, and although it is possible that it will never
have a widespread use, just as Dr. Little employed it, he
gave an impetus to the subject which was perhaps the origin
of the famous plaster-of-Paris jacket. His paper upon the
subject may be said to be classical.*
During the civil war, on several occasions, Little's ser-
vices were furnished to the Government. He was for a
time surgeon-in-chief to the hospital erected on the edge of
the City Hall Park, and twice, at least, after great battles,
he volunteered with those other New York surgeons who
went to the front at the call of the Surgeon-General. Now,
as then, the avenues to professional success as a teacher
and consultant began at service in dispensaries and clinics.
•Dr. Little was engaged in such work from the days when
he was a medical student and a substitute for the junior
walker in the hospital until his death. One year after leav-
ing the hospital he was appointed clinical assistant to Dr.
Parker, who was then professor of surgery in the College
of Physicians and Surgeons. In 1863 he was appointed a
lecturer in the college. His first course of lectures was
upon " Fractures and their Treatment." These lectures
were continued until 1868, when his chair wTas enlarged to
that of " Operative Surgery and Surgical Dressings."
Dr. Little was very popular as a lecturer. His manner
was exceedingly simple — in fact, at first distressingly so ; but
it was earnest and devoid of mannerisms and self-conscious-
ness. One of our most successful teachers lately said to
me : " Little did not merely tell the men to apply a flax-
seed poultice, but he brought the flax-seed and the cloth to
the lecture-room and made the poultice before the class.
Then they knew how it was done, for they had seen it."
Indeed, his teaching was realistic to a degree. The man
was thoroughly in love with his work. He was alive to
every progressive tendency ; he traveled in no rut, but was
always on the alert to assist in making surgery the exact
science it is so fast becoming. He took great pains with
the illustration of his subject by diagrams and drawings,
which were prepared by competent men under his direc-
tions with great care. An examination of his library after
his death showed that he had ransacked the surgical pic-
tures of Great Britain and the Continent to secure the best
illustrations for his lectures. Certain it is that not a little
of the fame of his alma mater for thorough teaching was
due to Dr. Little's lectures, although they were given in the
summer term, and attendance upon them was not obliga-
tory. They were continued for sixteen years, when he re-
• signed from the position he held in the college as a lecturer
on surgery, and one of the staff of Professor Markoe, who
has succeeded Parker, to accept the appointment of professor
of clinical surgery in the University of New York.
But Little's best qualities as a surgeon, a teacher, and
an executive officer were seen after his acceptance of the
chair of surgery in the University of Vermont. This was
in 1875. He had previously declined an offer of a similar
chair in the Long Island College Hospital. He entered
* " Trans, of the Am. Med. Assoc.," 1867 ; "Med. Record," 1874.
upon the work in Burlington with great zeal. There he
found a medical college that still survived the vicissitudes
of forty years, although those at Woodstock and Castleton,
in the same State, had been abandoned. It had about sixty
students. Little's keen perception of the possibilities of
this field showed him that they were great. The lately
elected president of the University, Dr. Buckham ; the ven-
erable Carpenter, professor of practice; with Thayer of an-
atomy, King of obstetrics, and Darling of anatomy, were
fully alive to what lay in store for the Burlington Medical
College. TJiere was a reason for the existence of a medical
college there. It was needed to supply the demand for
medical education for a large number of young men from
Vermont and northern New York, who could not conve-
niently go to Boston, Philadelphia, or New York.
The academical department, at the laying of whose cor-
ner-stone Lafayette had assisted, embraced in its faculty
many soundly educated and cultured men, whose sympa
thies were readily enlisted for any good scheme for the cul-
tivation and dissemination of human knowledge. They
seconded the efforts of the president to give character to
the various departments. The medical school acquired a
certain dignity by its name, and it had that not unimport-
ant advantage over the schools that formerly existed in the
same State. Many young men, exceptionally well prepared
by previous training, found it more convenient to study in
Burlington, on account of the greater expense attending a
long stay in a large city ; and many practitioners of Ver-
mont and northern New York found the clinics and lectures
of the medical department of the University an accessible
post-graduate school, which lighted up many a dark subject,
and gave them a little recreation from their lonely and re-
sponsible duties as country physicians. The professor who
went to Burlington from a metropolitan medical college
soon saw that he had as intelligent and as earnest listeners
as at home, and that he must relax nothing in his efforts to
teach his science and art. With the hearty co-operation of
the president of the University, who presided at all the
faculty meetings, and his own colleagues, Professor Little
immediately began to devise plans for increasing the fame
and usefulness of the school. By personal solicitations in
many instances he was largely instrumental in securing
courses of lectures and clinics upon subjects not fully, if at
all, embraced in the general curriculum, hy specialists from
colleges in our city. Then Miss Mary Fletcher, acting large-
ly upon the advice of President Buckham and Professor Car-
penter, founded a hospital, and, with a broad-mindedness not
always seen in those who found hospitals, gave up its wards
unreservedly to the teachers of the college. This was natu-
rally of the greatest importance to the success of the school,
for the day had passed when didactic lectures unillustrated
by subjects were considered fit means of teaching medicine
and surgery. Little's facilities for the performance of great
operations were largely increased by the foundation of the
hospital. His clinics were sought by crowds of patients from
far and near. During the weeks that he lectured in Bur-
lington the streets of the town gave evidence, by the pass-
ing through them of numerous people with surgical dress-
ings on some part of the body, and by the great accumula
508
ROOSA: THE LIFE OF JAMES LAWRENCE LITTLE, M. D.
[N. Y. Med. Jook.,
tion of the mud-stained buggies of the practitioners of the
adjacent towns, as well as by the over-filled wards of the
hospital, that a great deal of surgical work was going on.
Stimulated largely by Little's surgical feats, and by an ex-
ecutive capacity heretofore, from the want of an arena, not
known to belong to him, the college grew apace in charac-
ter, in importance, and in the number of students. A new
building was given to the faculty in 1884, by the late Mr.
Howard, and, when Dr. Little died, more than two hundred
and twenty students in the class-rooms of the college mourned
the loss of their professor of surgery.
In an address commemorative of Darling and- Little, Pro-
fessor A. F. A. King sketches the introduction of the latter
to the class in a manner so graphic and descriptive of the
man that it is here reproduced. Dr. King says : " I intro-
duced him to the class, and I well remember his modest
embarrassment, which would, however, have passed unno-
ticed by the students had he not said, in the course of his
first disjointed remarks, ' Fin a little nervous, as you see.'
But a patient was introduced, a diagnosis made, an opera-
tion decided upon, and a knife handed to Professor Lit-
tle, and I can tell you (as you know) he was not nervous
then,:'
To those of us who knew Little well it was interesting;
to see this preliminary nervousness when a great operation
was imminent. The quick, short steps, the restless tapping
of the foot when he was preparing for his work, gave little
promise of the bold, self-reliant man as he stood over the
patient, perhaps reeking with the perspiration of surgical
ardor, but yet with steady, skillful hand working in a man-
ner that convinced any one, competent to judge, that a life
given into his hands would be preserved and returned, were
it among human possibilities.
In Burlington, as in New York, "Little's luck" became
proverbial, for his operations, from causes that I am not
able to analyze or define, were pre-eminently successful. A
well-known surgeon in New York told me, in substance,
that it was a prevalent opinion in St. Luke's Hospital
that it would he safe for Little to cut off a foot of an intes-
tine, when another man could hardly touch it with a knife;
and yet he was deferential to a fault to the surgical opinions
of his peers, ready to adopt their suggestions, and to give
proper credit for them. He was a man who exhibited great
common sense as a surgeon. He was not overtrained, but
he knew how to get at the upshot of a case without being
unduly anxious as to how Esmarch or Lister was doing
that thing now.
Dr. Little's chair in the University of New York was
never a satisfactory one to him. His clinics there were
held but for a part of the session, and he taught but once a
week, although his classes were large, and the students, at
least on one occasion, petitioned the faculty that his instruc-
tions might be continued throughout the session. The re
quest could not be granted, on account of the pressure for
time in which to give the whole curriculum. Three years
after his acceptance of the position, together with six mem
bers of the former post-graduate faculty of the University,
he resigned, in order, in conjunction with them, to establish
the New York Post-Graduate Medical School. To this in
stitution he gave the same hearty effort that he displayed
in Burlington. His lectures to graduates were, if possible,
better appreciated than by the under-graduates whom he
had instructed since his early manhood. A doctor was to
him a brother. Without quite knowing it himself, he acted
as if he supposed that every man who sought or had ac-
quired the degree of M. D. was as eager and honest in the
pursuit of knowledge with which to save life and mitigate
disease as he was himself.
It is said that he always leaned toward the student, and
possibly too much, when required to vote upon his examina-
tion in the faculty at Burlington. This was not from any
idea of lowering the standard of proficiency, but because he
could not be made to understand that there were men who,
unlike himself, regarded medicine as a business, in which
they were willing to embark with as little capital as could
make a fair show. During these last three years he ex-*
hibited his best qualities of faithful work, and if, as Dr.
Lloyd, one of his former office students and valued assist-
ants, says, " he was inclined to throw off his work on other
shoulders, and less inclined to undertake long and serious
operations," on account of some grave symptoms in his
general health, it was not apparent to those of his friends
who saw him only at intervals. The last public work he
was engaged in was a meeting of the Post-Graduate Facul-
ty, on the evening of March 31st, when he appeared in his
usual health and spirits. At that meeting an incident oc-
curred which was characteristic of the man. He felt im-
pelled by his judgment to vote, on a question which then
came up, contrary to his feelings. It was a question that
might affect the interests of some to whom he was attached,
and, after he had voted and he was found to be in the ma-
jority, he expressed his regrets that he should be obliged to
vote for a policy which might prove detrimental to the in-
terests of a friend, and he vainly sought for a compromise
upon the subject.
Dr. Little's services to St. Luke's Hospital were very
great, and they were warmly appreciated by his patients,
his colleagues, and the management. He served one term
of ten years, from 1868 to 1878, when he was retired under
the rules to be made a consulting surgeon. In 1882 he was
reappointed an attending surgeon, and held the position un-
til his death. Little used to tell a story of an experience of
his at St. Luke's which well illustrates the maxim that " all
men think all men mortal but themselves." He was to
operate, on one afternoon, upon two cases for resection of
the upper jaw. The first patient died upon the table from
getting blood in the trachea, and Little sent word to the
survivor that he wished to postpone the operation for him.
He was very much disappointed at the delay, and urgently
insisted that Dr. Little should personally visit him in the
ward and tell him why he did not wish to operate upon him
as appointed. The surgeon accordingly went up, and with
some hesitation, on account of the probable effect upon the
hopes of the candidate for an exsection, frankly told him
that the first man was dead, and he did not feel like going
on with a case of the same kind just at the moment. But
instead of being daunted the patient exclaimed, " Oh, that's
nothing ! I'm not afraid. The other man was a sickly
Nov. 7, 1885.J
ROOSA: THE LIFE OF JAMES LAWRENCE LITTLE, N. D.
509
fellow. I never thought he would get through. You oper-
ate on me. I won't die." As a matter of fact, Little did
soon operate upon him, he got no blood in his trachea, and
he did not die.
In 1876 Dr. Little was appointed an attending surgeon
to St. Vincent's Hospital, a position which lie held when he
died. Little alwayS believed that the kind offices of the
Rev. Vicar-General Quinn, one of the managers of that hos-
pital, were largely instrumental in securing him this posi-
tion. The Vicar-General was a priest in the wards when
Dr. Little was house surgeon in the New York Hospital,
and in his visitations to the sick and dying in the wards
had been struck by the commanding presence, the assiduous
and faithful labors of the young surgeon.
Of Dr. Little's surgical achievements in detail I am not
competent to speak, nor is it necessary that I should do so.
They are indelibly recorded in surgical literature — at least
in part, for of late years Dr. Little was somewhat regardless,
from lack of time, perhaps, from his large and exacting
public and private practice, to write as much as his friends
might have wished. But I may say that he was the first
American surgeon to puncture the bladder with tbe aspira-
tor for the relief of retention of urine. He simultaneously
ligated the subclavian and carotid arteries of the right side
for aneurysm of the fine part of the subclavian. The opera-
tion for stone by various methods he had performed seventy-
seven times, with a fatal result in but two cases. In hare-
lip and strangulated hernia he also had a large and success-
ful experience. He entered into the advances claimed to
be made by antiseptic surgery with great enthusiasm, and
on his last visit to Europe, at the meeting of the Interna-
tional Congress in London, he investigated Lister's methods
very carefully, and came back to carry out all the details of
Listerism in capital operations. He was a surgeon who
looked round upon a far horizon. Very few operations
were foreign to his knife. Yet he was extremely apprecia-
tive of specialists, and, while not heeding their advice so
much as some of those who have looked askance at them,
he frequently sought their aid, and often publicly recog-
nized their value in enlarging the field of exact knowledge.
He himself used the ophthalmoscope, the laryngoscope, and
other means of examination not always used by general sur-
geons, so that he was- singularly competent to make an ex-
amination in any surgical case. In the practice of medicine
also — for he by no means confined his work to surgery — he
was suggestive in the matter of treatment, and had many
celebrated prescriptions upon which he drew with great
readiness and accuracy.
Little was a great admirer of his instructor, Willard
Parker. He gave his first-born the name of his preceptor.
Dr. George Shrady styles him one of his worshipers. So
great was this admiration when he left the hospital that
some of his friends feared he would be content to be an
imitator and never strike out for himself. He seemed to
have acquired Dr. Parker's art of making surgery fascinat-
ing to students ; he drew them about him in great num-
bers. Even if the clinical material for his hour, on any
particular day, was scanty, the lecture would not betray the
want, for what was there was made the subject of homely
but important lessons. The capacity for dignifying the
every-day work of surgical practice, for making apparently
minor things and details assume their true importance, be-
longed to him in a great degree. He could make a good
clinic from material which some surgeons would not deign
to spend a moment upon. Like AVillard Parker, also, he
attracted to himself numerous office students, who almost
invariably became much attached to him.
Dr. Little was, in the good sense, a simple-minded man.
He loved to sit down in such places as the office at the hotel
in Burlington, and, as he became warmed in his discourse,
talk to plain laymen, who understood but half of what he
said, of tumors and ligations, of resections and ovarioto-
mies, and all without any idea of boasting of his own deeds,
for he had not the faintest resemblance to a braggart, but
he was so interested in surgery that, like Agassiz, who
talked about his study of the skeletons of fishes to stage-
drivers, he fairly bubbled over upon the subject. He was
fond of the meetings of the profession. After its founda-
tion, the New York Surgical Society was his favorite place
for recounting his experience and listening to the discourse
of the distinguished men who organized and maintained this
body. He was one of the signers of the address to the
profession of the State against the re-enactment of the Old
Code, and the movement to liberalize the profession had his
full sympathy and co-operation. Social to a degree, he
could be found late in the afternoon in the conversation-
room or at the monthly meetings of his club, with a cigar
for himself and for his neighbor, ready to discourse upon
any subject that was uppermost in men's minds. He gave
great thought and spared nothing in the education of his
two sons and a nephew. He had almost exaggerated ideas
of the importance to a young man of an exact and thorough
course of study in a college. He did not practice his pro-
fession with an idea of amassing a fortune, but he conceived
that it was better to thoroughly educate his sons than to
leave them the few dollars which a niggardly economy
might have allowed a physician dying in middle life to put
aside from his professional income. Before his death he
had the great satisfaction of seeing his eldest son fully
equipped and prosperously entered upon the practice of a
lucrative profession. In his latter years he interested him-
self very much in the study of china and bric-a-brac. It
became a recreation to him to visit auction-rooms, and often
he came away with a rare bit of some kind.
Galton describes a certain class of men as being incapa-
ble of advancing beyond a certain point in mental attain-
ment, just as another class can only be developed physically to
a certain inferior standard. Little was not one of these. As
long as he lived he grew in mental capacity. He was never
satisfied with his own preparation for the study of medicine,
but, while he did not enjoy the advantages of a college
training that he appreciated so highly in others, he had that
which no conventional curriculum can of itself furnish — a
receptive, inquiring, and unbiased mind in science; and as
to merely scholastic attainments he might have well said as
did John Hunter when he heard that he was reproached by
a rival with being ignorant of the dead languages, " 1 would
endeavor to teach him on the dead body that which he
510
ROOSA: THE LIFE OF JAMES LAWRENCE LITTLE, 31. D.
[N. Y. Med. Joub.,
never knew in any language living or dead." It has been
said by one biographer of Dr. Little that he was a typical
American. It is certainly true that his career is a striking
example of how eminence in our profession is to be attained
by the resources of our own country. His education was
wholly obtained within his own city. He had none of the
advantages so useful to the best of men, so without use to
many, which are to be obtained in British or Continental
schools. But no man more than he appreciated the labors
of foreign surgeons and pathologists, no one followed more
eagerly the medical literature of his time ; but he was fortu-
nate enough never to acquire that slavish esteem for books
which would have led him to read so many as to cease to
think for himself.
The sense of humor was fully developed in Dr. Little.
From the busy and sometimes weary life of a general prac-
titioner, and from the society of his friends, he extracted
much to give zest to his work. A joke at his own expense
was almost as welcome as if for another. He used to tell
with great glee, and awaking much laughter as he did so,
how a little trick of his to stop too prolix patients once got
him into great trouble. He said that he had found a good
device for interrupting a needlessly long story on the part
of a patient was to ask, in the midst of the long narrative,
" Please let me see your tongue." He found that patients
bore this interruption very well, and that, in their eagerness
to get the doctor's opinion of this index of the digestion,
its wagging ceased. But on one evening a friend, who was
in no sense a patient, was making a call upon him, and
talked long, when Little was very tired. After a time the
doctor's mind wandered afar off from the discourse to the
discussion of medical cases and questions, and, turning to
his friend, who was in the full tide of talk, he asked with
great gravity, " Please let me see your tongue." Little was
never able to explain what happened when his friend had
fairly taken in the meaning of this interruption.
But I must turn from the contemplation of the varied
sides of our late associate's life and character. A quarter of
a century was to be the limit of his professional life. In
the apparent ripeness not of old age, but of middle life, it
was ordered that his work should end. As has already been
intimated, he was actively engaged at a professional meet-
ing up to a late hour on Tuesday, March 31st, and on Satur-
day, April 4, 1885, he was in the life beyond. In August,
1884, it was discovered that he was suffering from diabetes.
I believe it is thought, by some authorities at least, that the
debility induced by this disease, the existence of which was
shown by the examination after death, made him less able
to resist the acute affection from which he died. At any
rate, it had a sensible effect upon his apparent feelings and
actions, as observed by his intimates. His thirst was
marked, and he became much fatigued upon slight exertion.
But he continued his daily work, without creating a suspi-
cion of the existence of any serious disease, in those who saw
him only at intervals, until Wednesday morning, April 1st,
when he called his friend, Dr. Lloyd, to his office, at about
ten o'clock, and he found him with his head resting upon his
hand and complaining of a severe pain in the right iliac fossa.
He asked Dr. Lloyd to attend to his clinic for that day,
while he proposed to make one or two calls in the after-
noon. He then went up stairs and took a dose of cathartic
medicine prescribed by himself. At noon he said he felt
better, and he went out to try and finish some work, but he
soon returned, complaining of severe pain. His family phy-
sician, Dr. John S. Campbell, was sent^for in the evening;
when Dr. Campbell arrived he ordered a dose of castor-oil,
which he had seen relieve similar attacks in Dr. Little. The
night passed without a movement of the bowels, and with a
steady increase in the pain. Early in the morning he sent
for Dr. Lloyd and gave him the necessary instructions in
regard to his practice. When Dr. Campbell came for his
morning visit he advised that Dr. Loomis be sent for in
consultation, and when he came, although he thought there
was beginning typhlitis, he advised a dose of calomel. He
also had seen Dr. Little in similar attacks, which had been
relieved by cathartics.
No alleviation of the pain was obtained, nor did the
bowels respond to the frequent calls made upon them ; and
on Friday, owing to the increase of the pain, it was found
necessary to resort to the hypodermic injection of morphine.
It was also noticed that there was a localized peritonitis,
and, when Dr. Campbell arrived, Dr. Sands was also called
in consultation. By the time he arrived, in the afternoon,
the inflammation of the peritonaeum had become general,
and it was a question whether it would be wise to operate.
This was advised against, however, when the existence of
the constitutional disease was fully considered. Although
the hypodermic was used freely all Friday night, it was
found on the morning of Saturday that the peritonitis was
much aggravated. On this morning he sent for Dr. Lloyd,
and when he got to the room he found him, in spite of the
peritoneal inflammation, sitting in a chair by the side of the
bed. As Dr. Lloyd entered the room he asked if he thought
he looked much worse than the day before, and then imme-
diately began to give instructions with regard to some busi-
ness for the University of Vermont, which he thought ought
to be attended to without delay. It was suggested to relieve
the distension of the bowels by an aspiration, but he ob-
jected, and the matter was not urged. Dr. Lloyd, from
whom I received these particulars, then continues : " After
remaining with him for some time, I left to attend to the
calls, and was probably absent about an hour. Upon my
return I was met at the door by one of the servants, who
asked me to hurry to the room, as the doctor was worse.
Hurrying up stairs, I found Drs. Campbell and Powell al-
ready there, and that collapse had set in a few minutes be-
fore. Just before my arrival the doctor had asked Dr.
Campbell, 'Doctor, don't you think a little digitalis would
be good for this failing heart of mine ?' Dr. Sands was also
sent for and arrived in a very few minutes ; but there was
nothing to be done, and we now knew that the end was
nearing fast. As I entered the room the doctor held out
his hand with the expression, 'Lloyd, I am going now';
and then, a minute later, again calling me by name, he said,
' I now realize the truth of what poor Beard said.' * Dur-
* This refers to the dying words of the late George M. Beard, in
which he expressed his regrets that he could not express the thoughts
of a dying man.
Nov. 7, 18M5.]
VANCE: CASES IN ORTHOPEDIC SURGERY,
511
ing all this time he was suffering intensely, but his mind
was entirely clear, and his spirit undaunted by the fast ap-
proach of death. He summoned the household servants and
family about his bedside, casting anxious glances at a clock
that was in his chamber, plainly showing that he was count-
ing the moments that he still had to live. Having bid fare-
well to each one by name, and with the words, ' I die in the
Christian faith ' upon his lips, there was a final instant of
distress, when this brave man yielded up his spirit to the
God who gave it."
(Original Communications.
CASES IN
ORTHOPEDIC SURGERY.*
By AP MORGAN VANCE, M. D.,
LOUISVILLE, KT.
Mr. President and Ladies and Gentlemen of the
Kentucky State Medical Society : As your Committee
on Orthopaedic Surgery, I submit the following cases in
operative orthopaedy as my report, prefaced by a few re-
marks in justification of the procedures in three of the
cases.
The ailment known as infantile paralysis is, and always
has been, the dread of the orthopaedist. It is productive
of almost half the cripples we meet, and is dreadful because
of the meager results attained by treatment, most of the
authorities now holding that all relief derived comes spon-
taneously, and the effects of treatment other than that to
prevent deformity and to promote locomotion are nil. This
has certainly been my experience so far in the effort to
revive the muscles which are lost.
The use of mechanical appliances for the purpose of
gaining the above-mentioned results is very unsatisfactory
for a number of reasons.
If we make apparatus strong enough to render constant
breaking less liable, it will be too heavy for the weakened
patient to manipulate at all, hence most patients soon dis-
card braces, either because of this or from their inability to
bear the expense of constant renewal. Deformity soon
takes place, and, as the patient grows older and heavier, hope-
less crippling is inevitable.
How many of these persons are daily seen on our streets !
some unable to help themselves at all, others showing every
degree of deformity with more or less disability. The
mechanical surgeon, therefore, is constantly on the alert for
new suggestions toward treatment.
It has been suggested, I believe, in England, and in some
cases acted upon, though the results have not been reported,
that the residue of the paralyzed muscles have a section re-
moved, thus gaining by an inelastic band better control of
the joint below. It has also been recommended, whether
carried out yet or not I am unable to say, that in some
forms of talipes calcaneus, for instance, the tendo Achillis be
resected, thus gaining an inelastic band, as mentioned above.
* Head before the Kentucky State Medical Society, June 25, 1886.
The third suggestion, and the one I have taken advantage
of, is to excise the useless joint and produce bony ankylosis,
thus doing by bone what we attempt to do by apparatus.
This seems at first glance to be very bold surgery, but,
when we look first at the utter hopelessness of these unfor-
tunates, and at the fact that the joints are alive and the bone
in young subjects healthy, we may hope for less risks than
when we get our prognosis from statistics of excisions where
bone disease exists. The greatest difficulty is the gaining
of the patient's consent. No surgeon should ever perform
any grave operation which is proposed for convenience with-
out making the patient cognizant of the risks he is under-
going. First, because it is not right; secondly, because if
it fails and the possibility of failure has not been explained,
it renders surgery too unpopular in that neighborhood.
The authorities for this class of operations are very
meager. In the latter part of 1881 I saw it mentioned in
a journal that Volkmann had suggested this procedure for
the knee and ankle where the muscles of the hip were left,
and that four or five operations had been done, with what
results I have not yet learned.
Not until May, 1882, did I succeed in getting a patient
to consent to the operation.
Case I. — Boy, aged Nine, Subject of Extreme Valgus from
Infantile Paralysis ; Unsatisfactory Use of Apparatus for Sev-
eral Years; Artificial Ankylosis produced, tcith Good Locomo-
Fio. 1 (Case I).— I3ef >re excision of the .mkh joint.
512
VANCE: GASES IN ORTHOPEDIC SURGERY.
[N. Y. Med. Jocr.,
tion resulting. — Ed. Lawrence, aged nine, of German parentage,
came under my care as a dispensary patient in the early part of
1882, giving the usual history of infantile paralysis occurring at
two years of age. Both limbs were at first affected spontaneous-
ly, recovery taking place to such an extent that only partial
paralysis of the left lower extremity remained, producing, as
the cut will show, a bad valgus.
He had beeD treated by various physicians, and had worn all
forms of apparatus without material benefit either as to the cure
of the paralyzed muscles or to locomotion.
At the first examination I proposed tbe operation of excision
of the ankle joint for the purpose of causing stiffness in the
best position for future usefulness, thus getting rid of all braces,
which had been faithfully tried.
Not for several months did I gain the consent of the parents
to the procedure, but finally, finding the foot fast assuming a
worse position as the boy grew heavier, and the brace more
often out of repair, consent was obtained.
Fig. 2 (Case I).— After excision of the ankle joint.
On May 13, 1882, the operation was done, Dr. J. W. Hol-
land administering the chloroform, and several other profes-
sional friends being present. A well-fitting, adjustable splint,
made of leather and hard rubber, had been prepared to receive
the limb.
The first step, after applying Esmarch's bandage to the limb,
was to make an incision, some three inches long, half way be-
tween the internal malleolus and the tendon of the tibialis-an-
ticus muscle in the axis of the extended foot, the center of
the incision being over the annular ligament.
When the joint was reached was it was opened and the foot
broken off the tibia, the ends of this bone and the fibula being
sufficiently exposed to allow of their being removed with the or-
dinary amputating saw ; then the upper surface of the astragalus
was shaved off with a stout bistoury through the cartilage and
sufficiently into the bone to insure that enough surface would be
freshened to produce bony union with the tibia and fibula. The
wound was closed with stitches, a counter-opening being made
for a rubber drainage-tube. No bleeding being present except
from the shaved surface of the astragalus, this was stopped only
after bruising the surface with the handle of the bistoury.
Surgical fever in this case ran as high as 102° F., but no very
alarming symptoms occurred, and within three weeks the ex-
ternal wounds were closed. I think this would have occurred
earlier had it not been for the great secretion of synovia, which
caused the wound to open several times.
Three years have now elapsed, and this boy has been
able to walk without apparatus and with no inconvenience.
There is at this date three quarters of an inch shortening of
that limb, with bony union of the astragalus to the tibia and
fibula.
A mistake was made at the first dressing of the foot by
placing it in slight extension, hoping thereby to more easily
overcome the effects of shortening by simply extending the
heel of this shoe. I believe this makes him step off this
foot in valgus still, despite the fact that the foot was set in
varus ; and has produced, by the greater strain, weakening
of the ligaments anterior to the astragalo-tibial junction.
From this mistake, the result is not so good as it would have
been if the foot had been placed at right angles, though
the result obtained decidedly justifies the means.
Case II. — Boy, aged Seven ; Subject of Infantile Paralysis,
of Six Years'1 standing ; Partial Spontaneous Recovery of One
Limb, the other almost completely Powerless and Greatly De-
Fig. 3 (Case II).— Before excision of the knee joint.
Nov. 7, 1885. J
VANCE: CASES IN ORTHOPAEDIC SURGERY.
513
formed; No Locomotion without Crutches ; Excision of Right
Knee followed by Bony Ankylosis, with Relief of Deformity
and Great Improvement in Walking. — Charley Hadfield, aged
seven ; subject of infantile paralysis since ten months of age,
both lower extremities being affected; the left had spontane-
ously improved to such an extent that, comparatively speaking,
it had become quite useful.
Many forms of apparatus had been worn and every known
treatment had been tried, and, from the history, I should judge
very faithfully.
The photographs will better show this child's condition than
I can by any written description. Suffice it to say, as the boy
grew older he more fully realized his helpless condition, and
kept complaining that his father would not have anything done
for his relief.
The case came under my observation three years before its
last appearance, and I had then advised the operation afterward
done. The father, remembering this, came again and consented
to it, after understanding its full gravity and assuming his share
of the responsibility.
Fig. 4 (Case IT). — After excision of the knee joint.
I went so far as to let him hear a discussion upon the pro-
priety of this form of operation by the members of the Medico-
Ghirnrgical Society of Louisville, which was not at all favor-
able to its performance.
On October 21, 1884, after an open splint, made of leather
and hard rubber, had been prepared, the operation was done in
the presence of a number of professional friends, Dr. J. M. Ray
administering the ether.
As shown by the photograph, the limb was greatly de-
formed, the leg flexed, rotated, and partially luxated outward
and backward. On account of this deformity, the first step in
the operation consisted in making an incision longitudinally
along the inner border of the patella, having for its center the
joint. Before turning the bones out to be sawed off the patella
was removed, then the ligaments were divided and the ends of
the femur and tibia easily exposed and removed with an am-
putating saw. There was no ha3tnorrhage, as in Case I, as the
sawing closed the cancelli. The external ham-string was left
untouched, it being the only muscle of the thigh which had
any vitality left, and by its contraction had produced luxation
and rotation of the tibia. This muscle served as a perfect ten-
sion band to hold the bone in apposition.
There was little or no shock following the operation, and
the limb was at once placed in the splint. Ten hours after the
patient was placed in bed the temperature was found to be
105° F. Reasoning that nothing but malaria developed by sur-
gical procedure could produce such a fever as this in so short
a time, quinine was used liberally with the effect desired, and
had to be kept up for a considerable time.
The boy suffered little during his convalescence, and was con-
fined in bed for eight weeks before the wound closed; during
this whole time there was an excessive discharge of synovial
fluid, as in Case I. His general health was much improved, as
will be noticed by the difference in his appearance as shown by
the photographs.
The only accident occurring during his convalescence was at
about the end of the third month, when the wound and counter-
opening reopened completely, following the formation of pus.
Fig. 5 (Case III) — Before excision of the ankle joint.
The child had been walking about with the convalescent
plaster dressing still on, and had probably bruised the limb, or
5 14
VANCE: CASES IN ORTHOPAEDIC SURGERY.
[N. Y. Med. Jodb.
»
there was slight exfoliation of bone, causing the pus formation,
which, being confined under the dressing, forced the wound
open from end to end, instead of discharging, as is usually the
case, from a small opening at the point of least resistance.
Eapid healing soon took place, and the boy has been perfectly
well since. Firm bony union now exists at the site ot the kuee,
and the boy is able to stand without the aid of crutch or sup-
port of any kind, and can walk quite well.
The long confinement produced weakness of the left limb,
hut this is fast gaining strength by use. 'The action of the hip
is pendulum-like, as there is little or no power to flex the thigh.
The foot in this patient was in a state of equino-varus, and was
straightened during his confinement. If a proper shoe is worn,
no operative interference will be needed, as was at first antici-
pated.
Case III. — Case of Talipes Equino -Varus from Infantile
Paralysis in a Young Woman aged Twenty-five; Complete Cor-
rection by Tenotomy and Retentive Apparatus ; almost Complete
Relapse after Four Years; Excision of Ankle Joint, with Cor-
rection of Deformity and Good Locomotion anticipated. — Feb-
Fio. 0 (Case III). — After excision of the ankle joint.
ruary 6, 1885, Emma Moore, aged twenty-five, infantile paraly-
sis of right lower extremity, resulting in talipes equino-varus.
Four years ago, deformity relieved by tenotomy and retentive
apparatus, which was used, until worn out, with comparatively
good locomotion ; then a rapid return of the deformity. At
this second appearance excision of the ankle joint was proposed
and readily, under the existing circumstances, consented to, as
she was unable to get about at all.
The patient was placed in the City Hospital of Louisville,
nnd the operation done before the medical classes, February 6,
1885, Dr. J. M. Hay giving ether. After the haemostatic band-
age was applied, a longitudinal incision was made, just anterior
to the external malleolus, about three inches in length ; the tip
of the fibula was snipped off with the bone-pliers to facilitate
the breaking of the foot off the tibia, which was then easily ac-
complished, the articular cartilage being removed by an ampu-
tating saw from the tibia and by Hay's saw from the astragalus,
there being little or no haemorrhage, the ligaments acting as
tension bands to help hold the bones in apposition, as the ham-
strings did in Case II.
An adjustable splint had been made to receive the limb and
hold it at rest in the best position. Upon examination of the
pieces of bone removed, quite a good deal of what appeared to
be fatty degeneration was found in that taken from the tibia,
while that from the astragalus appeared firm and healthy.
Prognostications of a fatal result from osteomyelitis and
subsequent drain were freely made by my professional brethren
present. Notwithstanding the many disadvantages in the way
of surroundings and an intercurrent dysentery, she made a good
recovery, the only surgical complication being the appearance,
about the third week, of a diffuse cellulitis of the anterior part
of the calf, yielding readily to treatment.
At the date of obtaining the photograph the patient was in
splendid condition, the foot in good position, bony union be-
tween the astragalus and tibia secured, and she could bear her
weight on this foot, though not allowed to walk on it yet,, for
fear of irritation and renewed suppuration.
Case IV. — Subcutaneous Osteotomy of the Femur below the
Trochanter for Angular Deformity of Thigh from Hip Disease;
the Great Crippling relieved and Good Locomotion obtained. —
June 11, 1884, Homer Colbert, aged nine years, the subject of
spinal caries and true hip disease, both long since spontaneously
Fig 7 (Cask IV).— Before the operation.
Nov. 7, 1885.]
FERN ALB:
HYSTERICAL HEMIANESTHESIA.
515
cured, the hip being ankylosed by bone at an angle of less than
90° with the pelvis, the deformity resulting being greater be-
cause of the spinal disease in high dorsal region, which took up
most of the power of compensation in the lumbar spine.
This boy could stand with difficulty by holding on to his
left knee and right hip, but could not walk, his mode of loco-
motion being on all fours. The patient was an inmate of the
Methodist Orphan Home, and ready consent to the operation
was obtained ; and, on the date mentioned, it was performed in
the presence of the visiting physicians of the institution and sev-
eral other professional friends. The patient was anaesthetized
by Dr. Senteny, and turned upon his right side. A block of
marble, well padded, was pressed tightly upward on the inner
side of the thigh as high as the perinseum would allow. The
chisel was entered just below the trochanter, the edge of the
blade being in the axis of the limb. It was then sunk by steady
pressure to the bone, then turned with the edge across the bone,
and driven, with sharp strokes of the mallet, through until its
hard substance on the other side was reached and partly entered.
The direction was then changed and the same amount of cutting
done in several directions until sufficient weakening had been
produced to insure our being able to complete the fracture.
Fio. 8 (Case IV).— After the operation.
Without removing the chisel, the edge of the padded block was
placed opposite the chisel and rested on the table, thus acting
as a fulcrum at the weakened point. The pelvis being fixed by
an assistant, a quick and forcible depression of the lower end
of the femur completed the fracture.
The chisel was then removed, and tenotomy of the muscles
going to the anterior-superior spinous process of the ilium was
done, when, without much difficulty, the limb was brought
down and fixed in plaster of Paris, 90° of deformity being
overcome. The wounds were dressed with compresses of ab-
sorbent cotton and the case was treated as a simple fracture,
going on to conclusion without a bad symptom, the boy being
able to walk at the end of five weeks. He walks now — when
the second photograph is taken — any distance without difficulty,
using an elevated shoe to compensate for about one inch and a
half shortening of the affected limb.
Case V. — Deformity of Left Lower Extremity in a Young
Man of Seventeen, the Result of Knee- Joint Disease of Many
Years' Standing, relieved by Subcutaneous Osteotomy of Lower
End of Femur. — A. B., aged seventeen years, came under ob-
servation last November for treatment. There were the history
and the evidence locally of an old inflammation of the left knee
joint dating back to early childhood. The limb was greatly
deformed, and he walked with painful inconvenience. The
knee was found with very little motion, flexed at an angle of
135°, the leg being very much rotated in its relationship to the
thigh; there was combined with this marked genu valgum.
The compensating deformity of the foot being quite great and
walking being painful, I was unable to get photographs in this
as I did in the other cases.
The procedure of dividing the bone was exactly as in the
preceding case, the final steps being much more difficult because
of the limited motion at the knee, and the fear that it might be
further damaged if too much strained by the use of the leg as a
lever ; but I succeeded by having the upper part of the bone fixed
by a very strong assistant, then, grasping the condyles in both
hands, with the application of sudden force downward, using
the same fulcrum as before, the fracture was completed and the
deformity overcome, after tenotomy of the external ham- string
tendon. The limb was dressed in plaster and went on to firm
union as a simple fracture.
The young man now walks anywhere without difficulty, and
is the possessor, comparatively speaking, of a comely limb, a
compensation of one inch and a half being added to the shoe.
June 21, 1885.
HYSTERICAL HEMIANESTHESIA,
AND ITS IMPORTANCE.
By F. 0. FERNALD, M. D. (Harvard),
WASHINGTON, D. C.
Our text-books of medical practice have so little to say-
on the subject of "hysterical hemianesthesia" that the
majority of practitioners understand neither the full mean-
ing of the term nor its importance as a symptom. The
symptom, although most commonly met in young women,
is not confined to any age or sex. The left side is far
oftener affected than the right. The anaesthesia, which is
limited to one side of the body (beginning exactly in the
median line) and to its members, and to the special senses of
the same side, is, in a strongly marked, typical case, abso^
lute; the sensibility of the skin to touch, pricking, pinch-
ing, heat and cold, induced and constant currents, is lost ;
the faculties of sight, hearing, smell, and taste on the af-
fected side are gone; the accessible mucous membranes also
have lost their sensibility; the muscular sense is absent;
the skin is cooler and paler than that of the sound side, and
bleeds only a little, or not at all, when pricked or slightly
cut.
516
FERNALD: HYSTERICAL HEMIANESTHESIA.
[N. Y. Med. Joor.,
As in other affections, typical cases are not often seen.
The variations are numerous; one or more of the special
senses may escape entirely or become only slightly im-
paired ; cutaneous sensibility may be merely more or less
dulled, or dulled as regards one or another kind of irrita-
tion ; different areas of skin on the affected side may differ
widely in the degree of anaesthesia.
There is no characteristic method of invasion ; the
trouble may come on suddenly, either with or without loss
of consciousness, or it may appear gradually. Its duration
may be days, months, or years.
Its departure may kbe 'sudden or gradual. There are
also motor symptoms, as a rule, and these are generally on
the same side as the anaesthesia. They may assume the
form of mere weakness, of paralysis, or of rigidity. In
cases of this sort the motor disturbance may pass off rapid-
ly, while the sensory disturbance remains ; sometimes the
two sets of symptoms pass off pari passu ; at other times
both may grow progressively worse.
There are no especial causes of an attack ; it has been
known to be produced by a strong impression on the emo-
tions, by a fall, and by a jarring or slight injury received in
railroad cars. But of most cases there is no assignable
cause.
A few rare cases have been reported which presented pre-
cisely the same clinical picture as hysterical hemianaesthesia,
and of which alcohol, chronic lead-poisoning, and organic
brain disease, respectively, were considered the cause. Be-
fore going further, it may be well to cite a few illustrative
cases.
Case I. — Hysterical Hemianesthesia with Hysterical Hemi-
plegia.— This patient came to the out-patient nervous clinic of the
Massachusetts General Hospital (in which the writer was assist-
ant). E. B., female, thirty-four years old, married, complained of
inability to use the right arm and right leg; was able to walk
with some difficulty by aid of cane; movements of arm and fin-
gers possible but awkward. This inability to use her arm and
leg had been going on for over two years. Previous to this
trouble she had pain in right shoulder and arm, which she at-
tributed to strain occasioned by housework, to which she was
unaccustomed. After two months of pain she suddenly became
hemiplegic. At the time of her visit to the clinic the knee-jerk
was normal ; no apparent atrophy of muscles on the affected
side. By black-board test, the field of vision of right eye
limited; color-perception also impaired in same eye; hearing
on this side dulled to both air and bone conduction; taste on
right side of tongue absent; unable to distinguish the odor of
turpentine in right nostril. Her general health was good. With
encouragement was able, after a few minutes, to walk without
the cane.
Case II. — Hemianesthesia from Chronic Lead-poisoning.
(Reported by Sturge, " Brit. Med. Jour.," London, 1878, i, p.
784.) — A man, fifty-two years old, employed in white-lead
works, treated in hospital for lead-colic; cured; returned to
work ; three days later noticed slight weakness in left arm and
leg; also observed diminution of sensibility of left half of body.
Complained of itching and tingling of left hand and foot; while
in hospital noticed dimness of vision in left eye, which has since
increased. Examination : Grasp of left hand weaker than right ;
no dragging of left leg, but says it tires quicker than the other;
power to resist forced extension or flexion of left leg diminished ;
no facial paralysis ; general sensibility much diminished on left
side ; same true of face and tongue ; in lower part of leg and in
foot sensation but slightly dulled; unable to smell with left nos-
tril, right normal ; hearing of right ear normal, but with left ear
a watch was heard only when placed in contact with that ear.
Treated with metal discs; no result. Remained in hospital
several weeks unimproved.
Case III. — Hemianesthesia Hue to Alcohol. (Reported by
the same author, loc. cit.) — Man; habitual drinker; had had one
epileptiform attack. For two years had paresis of right side.
Was admitted to hospital with delirium tremens, and at this
time was noticed to have muscular weakness and anaesthesia on
right side; amblyopia of right eye ; odors not perceived in right
nostril ; hearing of right ear enfeebled ; sense of taste much
dulled on right side of tongue. Hemianaesthesia remained sta-
tionary for ten days, then began to improve; five weeks after
admission, sight equally good on both sides; hearing improved;
smell normal ; general sensibility still slightly diminished on
right side. Treatment : Iodide of potassium, gr. xv per diem,
with bitter tonic.
Case IV. — Hemianesthesia Due to Organic Brain Disease.
(Mentioned by Sturge, loc. cit., but originally reported by
Tiirck, 1859.) — Female, twenty-two years old ; died six months
after an apoplectic attack followed by hemiplegia and loss of
special senses and general sensibility on right side. Autopsy
showed a patch of softening lying outside of optic thalamus,
which was intact; two thirds of the foot of the corona radiata
was involved.
Diagnosis. — Hysterical hemianaesthesia has one striking
peculiarity in the fact that the patient is usually unaware of
its existence, and that the physician himself is apt to over-
look it unless he makes his examination in a thorough and
methodical manner. Hence a short description of the prop-
er mode of making the examination may not be out of
place. To avoid deception, it is essential that the patient
should have his eyes closed during the testing of the cuta-
neous sensibility, and it is best that he should also not
know beforehand what is to be done. The test is made by
pricking with pin, by electric brush, by small bottles of
water at different temperatures, and by other means that
readily suggest themselves. This examination of the skin
should be the first test in the examination of the patient,
because, if any anaesthesia is found, it gives the key to the
affected side, and knowing this we can avoid being deceived
while testing the special senses. Always try the special
senses of the suspected side first ; otherwise the patient may
be self-deceived by mistaking what we may call the " after-
images " of the impressions that have been made upon the
well side for genuine impressions on the affected side.
Both sides of the body should be tested and compared
throughout. The field of vision is examined by the black-
board test described in Webber's " Nervous Diseases " as
follows : " If accuracy is required, it is necessary to use a
blackboard with a point of fixation, the patient being placed
at a distance of a foot from that point, with one eye covered ;
a bit of white paper or chalk is then moved from the out-
side inward until the patient can see it, and a mark is made
on the board. This is repeated at short intervals around
the central spot until we have marked out roughly the field-
of vision of the eye." The color test can be made in a
similar way by substituting bits of colored paper for the
chalk. Conduction of sound through the bone is tested by
Nov. 7, 1885.1
INGALS: THE TREATMENT
OF LARYNGEAL PHTHISIS.
517
a vibrating tuning-fork held between the closed teeth, while
hotb ears are closed ; air-conduction is tested by the voice*
tuning-fork, «jr watch, always having the other ear closed.
Nature does not draw sharp lines. Hence it is not
always possible to distinguish hysterical from non-hysterical
hemianaesthesia. Frequently, however, a doubtful case is
cleared up after several examinations and after carefully
watching it for a time.
The tendency on the part of general practitioners proba-
bly is to ascribe the symptoms to organic brain disease
rather than to hysteria. But organic disease is a very rare
cause of hemianaesthesia, for only four or five cases with
autopsical proof have been reported. The absence of men-
tal disturbance, of persistent cephalalgia, of facial paralysis,
of abnormal electrical reaction and of nutritive changes in
the muscles, of syphilis or history of it, point to hysteria.
Dr. Walton, of Boston, was the first to show that in hys-
teria the hearing is affected in a peculiar and characteristic
way in that bone-conduction is impaired or lost before air-
conduction is affected. However, a patient may not pre-
sent himself soon enough for the physician to observe this.
The concentric contraction of the field of vision and loss of
color-perception are also characteristic of hysteria. Hemi-
opia is the usual form of defect in cases where the visual
centers are involved by organic disease. Chronic lead-poi-
soning may be excluded if there be no history of lead, or
if no lead be found in the urine either before or after the
exhibition of iodide of potassium. The history will also
exclude alcohol. Finally, in many of these hysterical cases
there is a fluctuation in the symptoms quite characteristic ;
there may be, for instance, a complete transfer of all the
symptoms from one side of the body to the other, or re-
peated improvements, or even complete recovery, followed
by relapses — all utterly inconsistent with the hypothesis of
organic brain disease.
Malingering may be suspected, especially in railroad
cases where there is possibly a question of damages. It is
quite inconceivable, however, that a person, often a very
ignorant person too, should be able to simulate hysterical
hemianaesthesia in its entirety, with the peculiar modifica-
tions of vision, hearing, smell, and taste. The amount of
injury that may be incurred without pain in these hysterical
people is marvelous, and is satisfactory evidence against
malingering. Skerritt ("Brit. Med. Jour.," London, 1888)
tells of a case of this kind in which a finger-tip was chopped
off and a leg broken entirely without pain. The so-called
hysterical or nervous temperament is by no means a uni-
versal concomitant of hysterical hemianaesthesia. Many of
the most marked cases present no other symptoms whatever
of hysteria.
Importance of Hysterical Hemiantesthesia. — In all ob-
scure cases of nervous disease one should make it a rule to
look for hemianaesthesia, for, if that be found, the other
symptoms will most likely be of hysterical origin also. In
medico-legal cases, especially railroad cases, we have in this
symptom the strongest possible evidence against the theory
of shamming, behind which the defendants almost invariably
try to intrench themselves.
Treatment. — The treatment is highly unsatisfactory as a
rule, often useless. Some patients with hysterical paralysis
seem to have lost merely the " knack " of making the mus-
cular contractions essential to certain movements. A case
of this kind came to the writer's notice while assistant
in the out-patient nervous clinic of the Massachusetts
General Hospital. A man with hysterical hemianaesthesia
and hysterical hemiplegia, the motor disturbances being
especially marked in the leg which was powerless, appeared
on crutches, saying that his condition was brought on by a
slight shock received in a railroad car. In less than half an
hour spent at the clinic he was able to walk across the room
unaided by crutches, but awkwardly, however. This result
was brought about by having him fix his attention on cer-
tain muscles, while these were made to contract by the
stimulus of the faradaic current, after which he was induced
to imitate the movements by effort of will. He was then
told that if he came again on crutches it would be his own
fault. He did not give them up, however. He entered
suit against the railroad company, but recovered before the
trial came off. Massage, tonics, electricity, especially the
wire-brush, are sometimes of value. The application of
metal discs has been known to cure. A full description of
this mode of treatment is to be found in Bartholow's
" Therapeutics." Mental and moral influences and time are
the best curative agents.
1013 Fourteenth Street, Washington, D. C.
THE TREATMENT OF
LARYNGEAL PHTHISIS*
By E. FLETCHER INGALS, M. D., Chicago,
PROFESSOR OF LARYNGOLOGY IN THE RUSH MEDICAL COLLEGE ; PROFESSOR
OF DISEASES OF THE THROAT AND CHEST IN THE WOMAN'S MEDICAL
COLLEGE.
At a meeting of the American Laryngological Associa-
tion in 1883 I presented a paper on the subject of the
treatment of laryngeal phthisis. The views I then held have
been but little modified by my subsequent experience, and I
can hope to offer very little that is new to those who have
read it. However, the malady is one of so distressing a
character that it merits constant effort in seeking means for
its relief. I, therefore, have yielded to the request of the
secretary to present the subject at this time, with the hope
of eliciting a discussion in which much may be brought out
that will prove mutually advantageous to us and to those
who may hereafter come under our care.
In what I have to say I purposely confine myself to a
few suggestions concerning treatment alone, ignoring the
entire subject of pathology, aetiology, and diagnosis of the
disease.
I gave in detail, in my former paper, the history of sev-
eral cases, in which I endeavored to illustrate the methods
which, in my experience, had proved most successful in
meeting the following indications, viz. :
1. The relief of pain.
2. The cure of the disease.
3. The prolongation of life, if the disease could not be
cured.
* Read before the American Climatological Association, May 28
1885.
518
ALLEN: THE USE OF THE GALVANO-CAUTERY.
[N. Y. Med. Jocr.,
For the relief of pain I have had more satisfactory re-
sults from the use of a pigment consisting of morphine, gr.
iv ; carbolic acid, gr. xxx ; tannic acid, gr. xxx ; glycerin and
water, aa 3 iv, than from anything else I have ever tried.
It will usually benumb the parts for from twelve to thirty-six
hours.
In the intervals between the applications of this pig-
ment, sedative powders may be employed with benefit.
Sometimes great relief may be obtained by allowing the
patient to use the pigment at home in the form of a spray,
first diluting it with two or three parts of water, or even
employing it in full strength when we find that it is used
properly ; thus applied, it relieves the pain and checks
cough.
In mild cases, a sedative powder — consisting of mor-
phine sulphate, gr. j-ij ; benzoin, gr. xx ; bismuth sub-
nitrate, gr. xx ; iodoform, gr. xx — may be used by the
patient, and even in severe cases it will sometimes be
found very beneficial. Powders may be applied directly
to the larynx by means of a bent tube, or, in cases where
the throat is very sensitive, they may be thrown through
the nares with an insufflator, providing they are blown in
with considerable force at the moment of a deep inspira-
tion. In about half the cases where this method is tried
the application to the larynx will be thorough and satisfac-
tory.
For the cure of the disease, in the early stage when there
is simple hyperemia, the ordinary topical applications for
chronic laryngitis seem beneficial ; and, even later on, we
may hope sometimes to check the progress of the disease
by the same remedies, thus preventing the distress incident
to extensive ulceration and exfoliation of the cartilages.
At the time I prepared my former paper I had hope for
much benefit, in the ulcerative stage, from the application of
eucalyptol by means of a brush or a spray ; but my expecta-
tions have not been fulfilled, although I have found it use-
ful in a few cases.
While great reliance is placed on local treatment, the
constitutional malady, which is present in most, if not all,
of the cases of laryngeal phthisis, should not be neglected.
This requires the same treatment as uncomplicated pul-
monary consumption, and a cure of the local affection
can hardly be hoped for unless the pulmonary disease
can be checked, although life may be prolonged by
local applications for the relief of pain. In cases where
death is inevitable I follow still the general line of treatment
alreadyT suggested, which was clearly marked out in my for-
mer paper, and the results are very satisfactory. Two pa-
tients whom I reported cured in 1883 are still well. One,
Dr. J. C. G., who was reported as declining in health, died
four months afterward from hepatic disease, which caused
excessive enlargement of the liver, but he had no return of
the laryngeal affection.
Sometimes the epiglottis or the arytaeno-epiglottic folds
become the seat of the ulcerative process. There is then likely
to be so extensive a destruction of the tissues that the glottis
can not be properly closed in deglutition. In such cases
food and fluids pass into the larynx and give rise to such
severe paroxysms of cough or suffocation that patients
will abstain from food for days rather than endure the
agony sure to follow any attempt to swallow it. Under
these conditions topical applications can do *ery little, un-
less feeding is carried on through a stomach-tube. In other
cases, where the ulceration has not selected these parts or
advanced to such a degree, much can be done to prolong
life by the use of some local application to benumb the
parts and enable the patient to eat with comfort. For these
the pigment of morphine, carbolic acid, and tannin has
proved most beneficial.
From the new anaesthetic, cocaine hydrochlorate, I hope
for good results ; but my experience in its use has been so-
limited that I can not speak with authority. Thus far its
cost has prevented thorough experimentation. Applied in
a strong solution of from ten to twenty per cent., with a
brush or as a spray, directly to the part, it will probably
efficiently relieve pain for a few minutes, or for a time suffi-
ciently long to enable the patient to partake of a hurried
meal with some degree of comfort. However, the great
objection to its use in this manner is that, in most cases,
it is impossible for the physician to be in attendance at the
right time three times a day.
The addition of the cocaine to the sedative powder
already mentioned would doubtless add to its efficiency,
and would furnish an anaesthetic which might be applied
by the patient either directly to the larynx or, in the man-
ner spoken of, through the nares.
The combination of cocaine, gr. j, with gr. ix of pow-
dered starch I have recommended to be employed in this
manner. I have given the powder for home use in but one
instance, and then in the proportion of only two per cent.
The patient reported that it did no good whatever. Its
failure was probably due to the fact that so small a propor-
tion of the drug was used.
Lack of time has compelled me to confine myself in
this paper to my own experience; but I hope that what I
have said may call out the personal observations of others,
which will be far more valuable than anything I could com-
pile on the subject.
Note. — Since the foregoing was written, I have several times em-
ployed cocaine hydrochlorate in laryngeal phthisis, but the results have
been unsatisfactory in every case, except in reducing the swelling of
aryta?no-epiglottic folds.
64 State Street, Chicago, May 23, 1885.
SOME MINOR POINTS IN THE USE OF
THE GALVANO-CAUTERY*
By HARRISON ALLEN, M. D.,
PHILADELPHIA.
I desire to call attention to a novel means of applica-
tion of the snare to the removal of hypertrophied tissue and
polypoid growths in the nasal chambers. The single feature
of interest in the instrument employed is comprised in the
facility with which the loop is maintained in a heated con-
dition. The general shape of the instrument is essentially
that of the Jarvis snare. For the details and full descrip-
* Read before the American Laryngological Association, June 2 5
1885.
Nov. 7, 1885.]
tion of the instrument, reference is here made to an article,
hy the writer, in the " Journal of 'the Franklin Institute,"
April, 1885, and a second in Pepper's "System of Practical
Medicine," vol. iii.
The advantages maintained for the heafed wire over the
cold wire are as follows : First, the loop, being pressed
against a swelling whose base is broad, can be completely
imbedded in it. Secondly, the tissue embraced by the
loop can be removed with rapidity. Thirdly, the operation
is much less painful than the removal of growths with the
cold snare. Fourthly, the bleeding is insignificant in
amount.
Let me in addition speak of the manner in which an
electrode can be manipulated so as to reach with accuracy
points which are remote from the nostril, and which can
not be readily seen by the operator. A perfectly straight
instrument, when thrust directly back through the nose as
far as it will go, will reach, as is well known, the vault of the
naso-pharynx nearly at the spot at which inspissated mucus
is so commonly found. If the platinum-loop of the electrode
is bent at its middle to a right angle, and in this shape thrust
through the nose, the main axis of the instrument will be
found to touch the vault at its anterior curvature, while the
deflected portion will reach a point more remote. When
in this position, if the electrode is made part of the gal-
vanic circuit, the loop of course becomes heated, and will
imbed itself in the mucus, and the mass can subsequently
be withdrawn through the nose.
To reach surfaces at the plane of the posterior nares, it
is only necessary to withdraw the electrode from its posi-
tion at the vault until it is seen by means of reflected light
to rest upon the surface which it is desired to. cauterize. It
is always well to remember that the applications can be
made without the electrode being secured to the electrode-
handle. When the electrode is in position, the free ends
of the instrument, which project beyond the nostril, can be
lightly touched by the electrode-handle without in any way
endangering a change of position on the part of the loop.
The slightest motion on the part of the patient will simply
break the contact between the electrode and the connecting
wires. The method just narrated is especially useful in
cauterizing the membrane overlying the posterior surface of
the middle turbinated bone.
SURRENDERING TO DISEASE TOO WILL-
INGLY ; LARGE DOSES OF STRYCHNINE.
By G. SPRAGUE, M. D.,
CHICAGO.
The case reported in the issue of the " New York Medical
Journal " of June 20th, by A. D. Rockwell, M. D., New York,
of chronic myelitis, is one more of the frequently occurring
instances where medical men too often yield to discourag-
ing indications, not estimating at their value the usual
effects upon young subjects of wisely planned and long-con-
tinued treatment in a given direction, this being seconded
by the inherent tendencies in young subjects toward recov-
ery. Dr. Rockwell says in that report : " Four physicians,
including myself, who had become interested in the case,
519
regarded the condition as entirely hopeless." He adds that
" the father, in the face of a completely discouraging prog-
nosis, insisted upon unceasing efforts being made," the re-
sult being subsequent recovery.
The case was, " Miss B., aged sixteen," while on a Sun-
day-school excursion, sat upon a wet, cold rock until conges-
tion of the parts adjacent to the point of exposure was pro-
duced, this being followed by paralysis, as stated.
To illustrate the principle here contended for, we will
make brief mention of a case :
0. L., a book-keeper, aged twenty-two, of sanguine tempera-
ment, short stature, and very vigorous physique, feeling slightly
indisposed, applied to a young practitioner from a reputable
school, who gave the young man a wet pack, a mode of pro-
cedure commonly adopted in his practice, as he afterward stated
to the writer. The result of the too-long- continued wet pack
upon the body and limbs of the young man was — there being
no especial elevation of temperature present to meet the shock
— to produce congestion of the base of the brain and upper por-
tion of the spinal column, resulting in epileptoid spasms, these
recurring at frequent intervals during each day. lie passed at
once into the hands of another practitioner, who at the end of
nine days acknowledged his inability to control the manifesta-
tions. The writer was called to the case (two years have now
elapsed), finding the violence of the epileptoid spasms increas-
ing in violence. Pulse 115, temperature 102-5°, tongue coated,
and bowels not moving. Put the patient upon £-grain doses of
calomel, conjoined with a little aloin, each three hours, and
after the fourth dose the bowels commenced to move gently,
the evacuations being small and quite like tar in appearance.
The bowels were kept gently in action, the movements taking
on a healthy character on the third day. A blister was ap-
plied upon the upper poition of the spine, 4x4 inches. An
immediate abatement of the convulsions followed, to be suc-
ceeded, very naturally, by total paralysis of the left side, of
both motion and sensation. Ten weeks of treatment found
him on his feet, and, feeling pretty well, he asked the privilege
of going twelve miles out to spend a short time with a friend. I
granted this, with the understanding that he was to be immedi-
ately brought back to the city upon the first indication of any-
thing being wrong.
But while at bis friend's he was seen by an acquaintance
from New York city, who said, " Come with me and I will give
you a job at book-keeping." He went without advising me of
the movement, whicli would, of course, have been objected to;
worked ten days at his book*, was hauled to his boarding-house
in a hack, with total loss of motion and sensation in the left side,
as before. Medical attendance was summoned, and at the end
of a week he had the combined aid of three medical men. The
result soon was a declaration from the attendants, all concur-
ring, that the case was a hopeless one; that he could never
again walk. Upon this decision being given, his friends here
sent for him, and he was brought home, the family supposing
the case was, as stated, a hopeless one. I stated to the father
of the young man that I hardly concurred in that opinion; that.
I would give him the necessary attention if thoy would pledge
to faithfully second my movements in every particular; that
if he was no better in two months, perhaps ho would be in
four; and if no better in four months, possibly lie might bo in
eight; if not improved in eight months, perhaps at the end of a
twelvemonth we might see him on his feet. As before, there
was total loss of motion and sensation of left side, with obsti-
nate tendency toward constipation, which condition was care-
fully watched and attended to. On the principle that wc sel-
SPRAOUE: SURRENDERING TO DISEASE TOO WILLINGLY.
520
BOOK NOTICES.
[N. Y. Mud. Jock.,
dom have pronounced outward manifestations without the co-
existence of internal organic disease, the treatment was con-
ducted upon this proposition, early in the management planning
to place a blister, 3x3 inches, each third day, over the upper
twelve inches of the spiDal column. After the effect of the
third blister was obtained there were indications of improve-
ment. After the fourth had been brought to bear the improve-
ment was pronounced. Regarding other means used, mention
will be made under the heading that follows. As to the prog-
ress made, in four months the young man could walk, with the
aid of his staff, by sliding the left foot across the floor. Soon
thereafter he was on the street. Within six months he was
ready for duty ; a portion of last summer kept books for an ice
company, from 7 p. m. to 7 a. m., without injury. At this writ-
ing he is book-keeper for one of the city ice companies. There
is still a tendency to torpidity of the bowels, but no twenty-
four hours is permitted to pass without a movement being pro-
duced.
Large Doses of Strychnine. — Having before me, in
the issue of the " New York Medical Journal " of June
27, 1885, reference in the proceedings of the American
Neurological Association to the use of strychnine in large
doses, I take this occasion to say that in the case above re-
lated strychnine, in solution (I would in no case administer
the drug in pill form), was given in ^--grain doses at first,
gradually increasing until \ grain was given three times
daily for two months or more, no manifestations being
made other than steady improvement in the patient's con-
dition, with final recovery, as stated above. In a case of
nicotin poisoning, under my charge during the past four
years, with steady improvement, I have given strychnine in
tV *° i*F~gram doses for weeks together, three timas daily,
at such times as the pulse ranged from 60 down to 47 a
minute.
ooh flotues.
The Curability and Treatment of Pulmonary Phthisis. By S.
Jaccoud, Professor of Medical Pathology to the Faculty of
Paris; Physician to the Lariboisiere Hospital, Paris, etc.
Translated and Edited by Montagc Lubbock, M. D. (London
and Paris), M. R. C. P. (Eng.), Assistant Physician to Char-
ing Cross Hospital and to the Hospital for Sick Children,
Great Ormond Street, London. New York: D. Appleton &
Co., 1885. Pp. xiii-407. [Price, $4.]
The basis of this book is a series of lectures delivered in
Paris by the distinguished author in the months of December,
1880, and January, 1881, and it is written with all the enthusi-
asm of a Gallic nature as well as with a conviction based upon
extensive experience and study. It is a misfortune which the
translator realizes, and expresses in his introduction, that no
reference should be made to the bearing of Koch's bacillus upon
tuberculosis; but the lectures were given more than a year be-
fore Koch's discovery. This fact alone renders the author's
ideas concerning the pathology of the disease decidedly behind
the times. The outline of the work includes not only the sub-
ject of treatment, hut a preliminary portion on the nature and
curability of phthisis, comprising sixty pages. Treatment is
discussed under the following methods: (1) The prophylactic;
(2) the hygienic, including hydropathy and aerotherapy; (3) the
use of drugs ; (4) the use of mineral waters, including a residence
at suitable watering-places; (5) the climatic. Two distinct
clinical forms of the disease are recognized — the inflammatory
or pneumonic form, and the chronic or ordinary one (gray
granulation, miliary tubercle, etc.); but the author also agrees
with Grancher, who considers that from an anatomical stand-
point tubercular granulations and pneumonic infiltrations have
the same structure. He also believes that tuberculosis is an infec-
tious disease, though he admits his ignorance of the agent which
causes the infection, or the exact manner by which infection
occurs. He considers that malnutrition is the chief factor in
producing phthisis, and that, when upon that an irritative pro-
cess or actual inflammation of the lung is ingrafted, tubercle
results. The division of tuberculosis into hereditary, innate,
and acquired might be condensed by dropping the first of these.
One of the chief points which are insisted upon is that pulmo-
nary phthisis in all its forms is curable. The existence of cavi-
ties and the occurrence of haemoptysis need not, of themselves,
imply a prognosis of a fatal issue, the number of the former
and their size, or the number and quantity of the losses of blood,
being the important considerations. The principles which are
laid down concerning prophylaxis, the hygienic treatment, and
treatment by the use of drugs, are sound enough, but we find
nothing new or original in them. In the sections upon treat-
ment by mineral waters and a change of climate, however, the
richness of the author's experience is manifest. His directions
in regard to the various places which be recommends are based
upon personal experience from visiting these places, and the
data which he has collected concerning altitudes and barometric
pressure, prevailing winds and variations of temperature, con-
ditions of soil and moisture, together with the conveniences of
the various stations, and the effects produced upon patients in
the different stages of the disease, during many years of prac-
tice. All these enable him to speak with something like pre-
cision in regard to the results of a sojourn at any station which
he may recommend. It is a pity that we have not an analo-
gous work for American patients, since, unfortunately, the
treatment of pulmonary phthisis under the most favorable con-
siderations is an expensive affair, and the majority of our pa-
tients have neither the inclination to take so long a journey nor
the ability to bear the expense of a protracted residence at Ma-
deira, Davos, St. Moritz, the Engadine, Algiers, or any other
of the European or African resorts. With the great variety of
conditions as to soil and climate which our country affords, cer-
tainly the field is a rich one for investigation and for a book
similar in its bearings to the one under consideration. The
translator's work is exceedingly creditable, and we do not re-
call an obscure passage in the entire book.
BOOKS AND PAMPHLETS RECEIVED.
Harn- Analyse fur practische Aerzte. Von S. Laache, Re-
servearzt an der medicinisehen Abtheilung A des Reichshospi-
tals in Kristiania. Mit 21 Holzschnitten. Leipzig: F. C. W.
Vogel, 1885. Pp. viii-166.
Applied Medical Chemistry. A Manual for Students and
Practitioners of Medicine. By Lawrence Wolff, M. D., Demon-
strator of Chemistry, Jefferson Medical College, etc. Philadel-
phia: P. Blakiston, Son, & Co., 1885. Pp. 174. [Price, $1.50.]
Epilepsy and other Chronic Convulsive Diseases; their
Causes, Symptoms, and Treatment. By W. R. Gowers, M. D.,
F. R. C. P., Assistant Professor of Clinical Medicine in Univer-
sity College, etc. New York : William Wood & Co., 1885. Pp.
xi-255. [Wood's Library of Standard Medical Authors.]
A Memorial Sketch of the Life and Character of the late
Jacob Simmons Mosher, A. M., M. D., Ph. D., of Albany, N. Y.
By Willis G. Tucker, M. D. [Reprinted from the " Transactions
of the Medical Society of the State of New York."]
Nov. 7, 1885.]
LEADING ARTICLES.
521
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Poster, M. D.
NEW YORK, SATURDAY, NOVEMBER 7, 1885.
THE AMERICAN ACADEMY OF MEDICINE.
The Academy's recent annual meeting, a brief report of the
proceedings of which will be found elsewhere in this issue, was
one of unusual significance. This organization has not been
much given to scientific work in the past, but has rather occu-
pied itself with matters pertaining to the elevation of the stand-
ards of medical education throughout the country. In this re-
spect the meeting held in New York was no exception, but it
was notable for a proposition looking to a radical change in its
by-laws— so radical, indeed, as to amount, in case of its adop-
tion, to the complete effacement of the Academy's most strik-
ing peculiarity.
Section 2 of Article III of the present by-laws reads as fol-
lows :
" The Fellows shall be alumni of respectable institutions of learning,
having received therefrom — 1. The degree of Bachelor of Arts, or
Master of Arts, after a systematic course of study, preparatory and
collegiate. 2. The degree of Doctor of Medicine, after a regular course
of study, not less than three years, under the direction and instruction
of preceptors and professors. 3. When a candidate is an alumnus of a
foreign institution not granting the degree of Bachelor of Arts or
Master of Arts, a certificate or certificates, which shall be considered
as equivalent by the Council and Academy, may be accepted in lieu
thereof, provided he shall have subsequently received the degree of
Doctor of Medicine. 4. The Fellows shall also have had an experience
of three years in the Practice of Medicine, in one or more of its recog
nized departments, and shall have a good moral and professional char-
acter."
We have copied this section punctiliously, preserving the
glory of the capital letters, the Teutonic punctuation, and the
blunders of phraseology. In view of the Academy's lofty — not
to say pedantic — attitude, the temptation is great to touch more
pointedly upon these shortcomings, but just now we are not so
much concerned with the Academy's literary achievements as
with the proposed change in the substance of its by-laws to
which we have alluded. The purpose of an amendment, to be
acted upon at the next meeting, is to provide for the admission
of graduates in medicine, who, although they may be destitute
of literary degrees, "have distinguished themselves in medicine
and collateral sciences." Here we can . not refrain from a pass-
ing remark upon the phraseology of the proposed amendment.
Why '■'and collateral sciences"? Must future candidates have
distinguished themselves both in medicine and in more than one
other science? However, we take it for granted that the pro-
ponent's intention is to secure eligibility for medical men who
have shown a notable proficiency in either strictly medical at-
tainments or any one of the collateral sciences.
We are convinced that the American Academy of Medicine
would be taking a wise step by adopting an amendment plainly
setting forth what we infer to be the purport of the proposed
amendment, and we think the Academy has been fortunate in
having a president who was able and willing to present the
arguments in favor of such a change so forcibly as was done by
Dr. Gihon in his address, our reporter's abstract of which we
regret to have been compelled by the pressure upon our space
to abbreviate.
Another important amendment was proposed to Section 1 of
Article VIII, entitled "Discipline." The section now reads:
"The Fellows of the Academy, in their relations with each
other and with their fellow-men, agree to be governed by the
principles embodied in the present Code of Ethics of the Ameri-
can Medical Association, and by the Constitution and By-laws
of the Academy." We have italicized the words which it is
proposed to change. In place of "agree to," the amendment
reads toill ; and in place of " embodied in the present Code of
Ethics of the American Medical Association," it reads which
actuate educated and upright men in every profession. This
amendment, too, we think the Academy would do well to
adopt.
THE MEMORY OF WILLIAM HARVEY.
Two years ago we gave a detailed account of the pious act
of the Royal College of Physicians in causing the neglected re-
mains of Harvey to be incased in a fitting sarcophagus of its
own providing. But that was only a half-measure, and a fur-
ther duty yet remains to be performed. In another part of this
issue of the journal it will be seen that the Harvey Chapel is
still but a portion of a ruin. The parochial church of Hemp-
stead is depicted as in a condition that ought to be remedied at
whatever cost. Every consideration of propriety points to the
medical profession as the fitting source of the means wherewith
the restoration of this sacred edifice — sacred not only from its
ecclesiastical character, but from its having been made the rest-
ing-place of the mortal remains of one of the greatest men who
ever adorned medicine — is to be accomplished.
At the solicitation of the Royal College of Physicians the
descendants of Harvey gracefully waived their own privilege of
caring for his remains, and the parishioners of Hempstead
Church, nobly recognizing the propriety of a universal tribute
to Harvey's memory, now with equal grace confess their own
inability, unaided, to do adequate justice to the demand, and
are willing to share the honor with the medical profession at
large.
The physiologists of two continents — and with them all
practitioners of medicine in every nation — have daily profited
by Harvey's great discovery of the circulation of the blood, to
say nothing of his numerous other contributions to the ad-
vancement of medical science. That these other contributions
are of no mean character is plainly shown by the interest taken
in the fac-simile reproduction of their author's manuscript lec-
tures— a work of which also mention is made elsewhere in our
present issue. It is, therefore, not with any idea of doing a
favor to the people of Hempstead, or even to the profession ot
522
MINOR PARAGRAPHS.
[N. Y. Mki>. Johh.,
medicine in the mother country, that American physicians will
take their proper part in providing the means for restoring the
sacred edifice in which Harvey's remains were originally de-
posited, but with the conviction that it is nothing more than
the expression of a just feeling of obligation. We trust, ac-
cordingly, to be called upon shortly to record the accession of
goodly sums to the fund. Already, since our article was put
into type, and before our public announcement is made, we
have received a generous contribution, which we shall acknowl-
edge in our next issue, and we do not doubt that at the same
time we shall be able to acknowledge a number of others.
MINOR PARAGRAPHS.
THE METRIC SYSTEM.
Whatever maybe the absolute merits of the metric system,
as applied to physicians' prescriptions, in communities w7here it
has been a part of every man's education, from childhood up,
it is evident, as we have several times insisted on, that the at-
tempt to transplant it to America is beset with some practical
difficulties that are likely for many years to stand in the way
of its adoption. Not the least of these difficulties lies in the
fact that the use of the system adds an element of perplexity
to acts which in themselves are always more or less fraught
with danger — the writing and the compounding of prescrip-
tions. This objection has lately had an illustration that well
nigh proved tragical, a Jersey City apothecary having put up a
certain number of grammes of a violent poison, instead of the
same number of centigrammes, and having expressed the opin-
ion that his error was in part due to the confusing effect of the
metric system.
POISONOUS CAVIAR.
At a meeting of a Russian medical society, held last spring,
a report of which appears in a recent issue of the "Deutsche
Medizinal-Zeitung," condensed from the "St. Petersburger
medicinische Wochenschrift," Dr. Enoch made some observa-
tions in regard to several poisonous varieties of fish, especially
three Asiatic ispeciesof Schistothorax and the Japanese Tetrodon
inermis. It seems that the roes of these fishes retain their
poisonous qualities for a long period ; in one of Dr. Enoch's
experiments, a portion of roe that had been preserved in alcohol
for six months was given to a mouse to eat, with the effect of
killing the mouse within half an hour. The symptoms of the
poisoning consist of vomiting, purging, syncope, tenesmus,
cramps, and dilatation of the pupil, followed by collapse and
death. Apparently there is no guarantee that the roes of these
poisonous fishes may not find their way to the consumers of
caviar in the ordinary course of trade.
HARVEY'S MANUSCRIPT LECTURES.
We learn from the " Medical Times and Gazette " that the
Harvey manuscript lectures are soon to be published in the
form of a photographic reproduction of the author's handwrit-
ing, interleaved with a transcript in type. It is said that the
photographic work has been so successful that many of the pas-
sages are more legible in the fee simile than in the original.
THE NEW HAVEN HOSPITAL.
We regret to learn that the house staff of the hospital has
had reason to make some formal complaints to the governing
body of the way in which they have been treated. It is an
agreeable surprise, however, to find that the Prudential Com-
mittee seems, so far as we can judge from the accounts, dis-
posed to right any wrong that may be demonstrated. It is
pleasant, too, to be able to record the forbearance and discre-
tion of the house staff in declining to furnish the newspapers
with an ex-parte statement.
ETHER AS A TIPPLE.
The "British Medical Journal" says that, at a recent dis-
cussion on a temperance report made to the Diocesan Synod of
Armagh, in Ireland, reference was made by one of the speakers
to a practice alleged to exist in various parts of the North of
Ireland, that of drinking ether instead of whisky as an intoxi-
cant. In several instances, it was stated, the exces>ive use of
ether had caused insanity. Action was consequently taken
looking to legislation to prevent the unrestricted traffic in ether.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending November 3, 1885:
DISEASES.
Week ending Oct. 27.
Week ending Nov. 3>
Cases.
Deaths.
Cases.
Deaths.
37
8
39
9
24
3
34
5
Cerehro-spinal meningitis. . . .
0
1
4
5
1
1
5
1
46
25
51
18
1
0
2
0
The Health of Massachusetts. — The Secretary of the State
Board of Health reports to the Secretary of the National Board
of Health for the week ending October 24th: In 109 cities and
towns, with a population of 1,312,471, there was a total of 363
deaths, of which number 57 were referred to the principal in-
fectious diseases. No deaths were reported from small-pox.
The Health of Foreign Cities.— We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office since
the date of the last bulletin, October 27th : Montreal, Canada.
— For the week ending October 28th : 274 deaths from small-
pox in the city, and 73 in adjoining municipalities. Kingston,
Canada, October 23d, and Toronto, Canada, October 21st: Free
from epidemic diseases. Havana, Cuba. — For the week end-
ing October 22d: 25 cases and 12 deaths from yellow fever.
Matanzas, Cuba, October 21st, Nassau, N. P., October 17th,
Cape Haytien, Hayti, October 17th, and San Domingo, October
15th : Free from epidemic diseases. St. Thomas, D. W. I. — For
the week ending October 13th : 1 death from yellow fever, being
that of a passenger from St. Johns. Acapulco, Mexico. — Octo-
ber 11th: Pernicious fever still prevalent, though the general
health of the city is improving. La Guayra, Venezuela. — Octo-
ber 17th : City healthy. Reports from Caracas still unfavora-
ble. Yellow fever prevalent. Rio de Janeiro, Brazil. — For the
month of August: 14 deaths from yellow fever. London, Eng-
land.— For the week ending October 10th : 3 deaths from small-
pox, including one which occurred in the hospital-ship outside
the registration district. The disease is steadily declining.
Paris, France. — For the week ending October 17th: 5 deaths
from small-pox. Bordeaux, France.— For the week ending Oc-
tober 10th: 2 deaths from small-pox. During the month of
September there were 14 deaths from this disease. Rheims,
France. — For the week ending October 16th: 2 deaths from
small-pox. Cadiz, Spain. — For the week ending October 10th:
30 deaths from cholera. Gibraltar, Sjwin.— For the week end-
Nov. 7, 18^5.J
MINOR PARAGRAPHS.
523
ing October 11th : 5 cases and 2 deaths from cholera. Com-
munication with cholera-infected districts is unrestricted. Ge-
noa, Italy. — For the week ending October lllh: 5 cases and 3
deaths from small-pox. Venice, Italy. — For the week ending
October 3d: 10 deaths from small-pox. Riga, Russia.— During
the month of July there were 2 deaths from small-pox. St.
Petersburg, Russia.— For the week ending October 3d: 2 deaths
from small-pox. Warsaw, Russia.— For the week ending Octo-
ber 3d : 4 deaths from small-pox. Calcutta, India. — For the
week ending September 19th : 6 deaths from cholera. Colombo,
Ceylon. — From August 22d to September 12th: 22 cases and 12
deaths from cholera, and 2 cases of small-pox. Marseilles,
France. — No deaths reported since October 4th, and clean bills
of health are now issued to vessels clearing from the port. In
Italy, from September 23d to 27th, there were 690 cases and
382 deaths from cholera. In Spain, from March 4th to Septem-
ber 27th, inclusive, there were 267,fi89 cases and 98,929 deaths
from cholera.
Cremation and the "New York Health Department.— It
is stated that the sanitary officials of New York do not feel au-
thorized to issue permits for cremation until after certain neces-
sary modifications of the provisions of the Sanitary Code have
been made. In the mean time a number of bodies are said to
be awaiting cremation, being now stored in vaults in various
cemeteries.
The New York Medical Missionary Society.— The Train-
ing Institute and Home, at No. 118 East Forty-fifth Street, was
dedicated on Wednesday evening.
The Tyndall Foundation. —In accordance with the plan
which we alluded to some months since, the proceeds of Profess-
or Tyndall's lectures in this country have been divided between
Columbia College, Yale College, and the University of Pennsyl-
vania, for the foundation of scholarships in physics. The sum
allotted to Columbia College amounts to $10,800, and the Trust-
ees guarantee that the annual income shall not be less than $648.
The recipient of the income is to be appointed annually, but
may be reappointed from year to year.
Cincinnati College of Medicine and Surgery.— Dr. Charles
E. Caldwell has been elected to fill the vacant lectureship on
general pathology.
The "Eastern Medical Journal."— We understand that
Dr. C. E. Nelson, of New York, has severed his connection with
the journal mentioned.
Personal Items.— Medical Director Philip Landsdale was
among the passengers of the steamship Belgenland, which sailed
for Antwerp last Saturday.
Army Intelligence.— Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from October 25 to October 31, 1885:
Huntington, D. L., Major and Surgeon, U. S. Army. Detailed
on board to inspect Army and Navy Hospital buildings at
Hot Springs, Ark. S. O. 245, A. G. O., October 24, 1885.
McEldeury, Henry, Major and Surgeon. Granted leave of ab-
sence for four months from November 1, 1885. S. O. 246,
A. G. O., October 26, 1885.
Patzki, J. II., Captain and Assistant Surgeon. Appointed
member of board to meet at Forts Jackson and St. Philip,
La., on November 5, 1885, to select a site for the new quar-
ters for the ordnance sergeants at those posts. S. O. 230,
Department of the East, October 28, 1885.
Tome y, G II., Captain and Assistant Surgeon. Granted leave
of absence for two months, to take effect after the return
from leave of absence of Surgeon J. C. Baily (Major). S. O.
87, Division of the Atlantic, October 24, 1885.
Barrows, C. C, First Lieutenant and Assistant Surgeon. In
addition to his other duties, to take temporary charge of office
of the medical director, Department of Arizona. S. O. 102,
Department of Arizona, October 17, 1885.
Ewing, C. B., First Lieutenant and Assistant Surgeon (Fort
Leavenworth, Kan.). To accompany congressional com-
mittee, of which Hon. W. S. Holman is chairman, in its visit
and inspection through Indian Territory. S. O. 160, De-
partment of the Missouri, October 23, 1885.
Ives, F. J., First Lieutenant and Assistant Surgeon. Relieved
from temporary duty at Fort Laramie, Wyo., and ordered to
Fort D. A. Russell, Wyo. S. O. 106, Department of the
Platte, October 22, 1885.
Morris, E. R., First Lieutenant and Assistant Surgeon (recently
appointed). Assigned to duty at Fort Bayard, N. M. He
will continue on detached service under orders of district
commander. S. O. 160, Department of the Missouri, Octo-
ber 23, 1885.
Marine-Hospital Service. — Official List of Changes of
Stations and Duties of Medical Officers of the United States
Marine- Hospital Service, for the week ended October 31, 1885.
Austin, H. W., Surgeon. To proceed to Portland, Maine, on
special duty. October 31, 1885.
Carter, H. R., Passed Assistant Surgeon. When relieved, to
proceed to New Orleans, La., and assume charge of the ser-
vice. October 27, 1885.
Battle, K. P., Assistant Surgeon. Granted leave of absence
for thirty days. October 27, 1885.
Williams, L. L., Assistant Surgeon. To proceed to Chicago,
111., for temporary duty. October 28, 1885.
Society Meetings for the Coming Week :
Monday, November 9th: New York Ophthalmological Society
(private) ; New York Academy of Medicine (Section in
Surgery) : New York Medico-Historical Society (private) ;
New York Academy of Sciences (Section in Chemistry and
Technology) ; Boston Society for Medical Improvement ;
Gynaecological Society of Boston; Burlington, Vt., Medical
and Surgical Club (annual) ; Norwalk, Conn., Medical So-
ciety (private).
Tuesday, November 10th : New York Medical Union (private) ;
New York Surgical Society; Medical Society of the County
of Rensselaer, N. Y. ; Newark (private) and Trenton (pri-
vate), N. J., Medical Associations; Medical Society of Cam-
den County, N. J. (semi-annual — Camden) ; Norfolk, Mass.,
District Medical Society (Hyde Park).
Wednesday, November 11th: New York Pathological Society;
American Microscopical Society of the City of New York ;
Medico- Legal Society; Medical Society of the County of
Cayuga, N. Y. ; Pittsfield, Mass., Medical Association (pri-
vate); Philadelphia County Medical Society (conversation-
al); Worcester, Mass., District Medical Society (Worcester).
Thursday, November 12th : Harlem Medical Association of the
City of New York; Society of Medical Jurisprudence and
State Medicine ; Brooklyn Pathological Society ; New York
Physicians' Mutual Aid Association (annual, in the Hall of
the New York Academy of Medicine, 12 W. Thirty-first
Street, at 4 1\ m.) ; South Boston, Mass., Medical Club (private
— annual); Pathological Society of Philadelphia.
Friday, November 13th : Yorkville Medical Association (pri-
vate); Medical Society of the Town of Saugerties, N\ Y.
Saturday, November l/fth: Obstetrical Society of Boston (pri-
vate).
524
LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
fetters to tfee tfbitor.
PRIZE ESSAYS ON DISINFECTANTS.
Brooklyn, October 26, 1885.
To the Editor of the New York Medical Journal:
Sir : Inclosed you will please find a verbatim copy of a let-
ter from Dr. Henry B. Baker, in answer to my letter on " Prize
Essays on Disinfectants," appearing in the " Journal " of Octo-
ber 17, 1885.
Very respectfully yours,
A. H. P. Lkdf.
[Dr. Baker to Dr. Leuf.\
" Lansing, Mich., October 22, 1885.
" A. H. P. Lkuf,
" 199 Dean St., Brooklyn, N. Y.
" Dear Sir : Accept my thanks for a copy of ' New York
Medical Journal,' October 17, 1885, containing your article,
' Prize Essays on Disinfectants.'
"I think you are quite rigbt ; and, if I understand the sub-
ject, I agree with you entirely.
" Tliis is the first information I have received of the final
action by the committee ; but after I had voted on the subject
I was informed that the two other members of the committee
had voted as represented in your letter, so I presume you are
correct. I immediately protested as vigorously as possible, and
have not seen or heard anything further on the subject until I
received your article to-day.
" Very respectfully,
" Henry B. Baker.
" You are at liberty to make such use of this as you choose.
" H. B. B."
DIELECTROLYSIS.
10 West Thirty-fifth Street, New York, November 1, 1885.
To the Editor of the New York Medical Journal:
Sir : As you correctly state in your editorial, the " dielec-
trolytic " method is by no means new. I gave the matter a
pretty careful examination some ten or twelve years ago. In
the experiments then made I used two glass tubes, closed at one
end and filled with platinum wires, for conducting the current.
One of the tubes was filled with solution of iodide of potassium
and the other with thin starch-water. The open ends of the
tubes were then closed with gold-beater's skin. If these tubes
be now connected with the poles of a galvanic battery (15 to 20
cells) and applied on each side of the arm, in a few moments
the starch-water will become blue, showing that a portion of
the iodine has left the tube which contained it, traversed the
tissues, and appeared in the starch-water tube. The starch
tube should be connected with the positive pole of the battery.
Applying this clinically, I met with absolutely negative re-
sults. I know that the late Dr. Beard made some experiments
of a like nature, and I fancy that Dr. Rockwell has done so like-
wise. Yours respectfully,
H. G. Piffard.
COCAINE IN SEASICKNESS.
228 West Thirty-fourth Street, New York, November 1, 1885.
To the Editor of the New York Medical Journal:
Km: In the "Medical Journal" of October 31st Dr. Kessler
denies the ability of cocaine to palliate or cure seasickness.
Well, I am able to verify the statement of Dr. Manassein in toto.
I made this year two voyages across the Atlantic, crossed the
Channel three times, and found cocaine the remedy par excel-
lence ; but it must be given in repeated doses of a l-to-500 or a
l-to-1,000 solution. I even found the l-to-500 solution in deli-
cate persons too strong, and failure followed, whereas the lat-
ter acted well. May not Dr. Kessler's failures be ascribed to
the large doses, which we still are in the habit of using in too
many cases? The bromides are good for nothing, and, till some-
thing better turns up, I cling to the l-to-1,000 solution of cocaine
hydrochlorate, a teaspoonful every two hours.
Respectfully,
S. Lilientoal.
^roceebhrgs of Societies.
NEW YORK PATHOLOGICAL SOCIETY.
Meeting of October 28, 1885.
The President, Dr. John A. Wyeth, in the Chair.
A Cast of the Bladder.— Dr. Louis Waldstein, of the Mi-
croscopical Committee, reported that the specimen of exfolia-
tive catarrh of the bladder, presented by Dr. H. J. Boldt at the
jast meeting, contained but very few, if any, muscular fibers; it
consisted of a false membrane with some portions of the mucous
surface; its thickness was largely due to cedematous infiltration.
Dr. Boldt remarked that the body had been exhumed some
days after burial, and a physician had made an autopsy, but his
report had been very incomplete ; he had stated, however, that
the walls of the bladder were thickened and contracted.
Ulcer of the Duodenum.— Dr. W. M. Carpenter presented
specimens for two candidates. The first one showed an ulcer
of the duodenum, an inch by an inch and a half in size, situated
half an inch below the pyloric orifice.
General Carcinosis. — In the second case the specimens
were of more than usual interest, showing extensive carcinoma-
tous degeneration in various organs of the body in a girl thir-
teen years and six months old. Her father had died of phthisis.
It was probable that two cousins of her grandfather had had
carcinoma of the breast. The girl had always been very
healthy, and a year ago was a vigorous, romping child. About
the middle of August she complained of being tired, lost color,
and became listless. She suffered no pain at first, but after-
ward cried out with pain in the region of the spleen. Her appe-
tite was insatiable. On the 8th of September enlargement of
the abdomen was first noticed, and from this time the increase
in size in the region of the liver was very rapid. The patient
complained of "agonizing pain, which she always referred to the
region of the spleen. She died in August. At the autopsy it
was difficult to remove the liver, because of its great size; its
weight was twenty pounds. Cancerous nodules of various sizes
studded its surface. All of the organs of the body except the
lungs contained nodules. The specimen was referred to the Mi-
croscopical Committee.
Dr. Waldstein presented a specimen for a candidate, con-
sisting of a malignant or semi-malignant tumor of the great toe,
following an injury.
Fibro-Myoma of the Uterus.— Dr. H. Marion-Sims pre-
sented a round tumor of the uterus, about five inches in diame-
ter. The patient had been married eighteen years, had given
birth to one child, had always been remarkably healthy, and
had been regular in menstruation. Three years ago was the
commencement of her illness; she complained at that time of
dragging and lancinating pain in the hypogastric regions. The
speaker first saw her in October, the present month, when he
found the depth of the uterus to be four inches, and discovered
a movable tumor in the abdomen which he diagnosticated as a
Nov. 1, 1885.]
PROCEEDINGS OF SOCIETIES.
525
fibroid of the uterus. The patient was extremely fat, and, to
remove the tumor, it was necessary to make an abdominal in-
cision nine inches long. She rallied well from the operation,
and there were no signs of inflammation about the wound. On
the third and fourth days she complained of distress in the ab-
domen, and vomited a large amount of black fluid, some of
which entered the respiratory tract and caused death by suffo-
cation. The autopsy showed no suppuration about the abdomi-
nal wound; the organs were not examined.
Plates for the Support of Pedicle Skewers. — Dr. Marion-
Sims also exhibited some vulcanized-rubber plates with grooves
for the support of the skewers, which had a tendency to cut
into the abdominal wall.
Dr. J. B. Hunter had prevented the skewers from sinking
into the integument by means of flat buttons, but the plates
exhibited were preferable as being larger.
AMERICAN ACADEMY OF MEDICINE.
Ninth Annual Meeting, held in New York, Wednesday and
Thursday, October 28 and 29, 1885.
The President, Dr. Albert L. Gihon, of the Navy, in the Chair.
Wednesday's Proceedings.
The Study of Medicine- as a Means of Education was
the title of the first paper, read by Dr. Robert L. Sibbett, of
Carlisle, Pa., who first referred to the various elements in edu-
cation, considering time the most important of these. The medi-
cal colleges of the United States were not institutions to be
proud of. In this country two hundred and nineteen medical
colleges had been chartered, of which ninety-three had become
extinct, whereas in Canada only fifteen had been chartered, and
twelve remained, all regular. A preliminary examination, with
graded courses and frequent examinations, was heartily recom-
mended. A protracted course of academic training was neces-
sary for a proper study of medicine. A State medical examin-
ing board with full authority to examine all practitioners, irre-
spective of degrees, would do more to elevate the profession
than all other means combined.
Medical Supervision in Student Life.— Dr. Charles Mo-
Intire, of Easton, Pa., then read a paper, in which he assumed
that the times had changed ; that modern life made a greater
demand upon the time and energies of the individual, to the
detriment of his health and development. It was considered
impossible to diminish tasks and give more time to rest and
recreation. There was no way known to shorten the period of
rest, so something should be done for recreation. The plan
suggested was the usual one given by students on these subjects.
A careful physical examination at the beginning of school-life
and a series of graded bodily exercises under medical supervision
throughout school-life were recommended. Many appeared to
be ignorant of the end to be obtained by a modern gymnasium,
so that in colleges the parents of the pupils were afraid that
their children would be injured by the gymnasium. But, as the
weaklings were the subject of special care and direction, they
were the ones least apt to be harmed and most likely to be im-
proved. The end aimed at was to give such tasks as would
tend to strengthen the weaker parts.
The Climatic Treatment of Disease, with an Illustra-
tion of Western North Carolina as a Health-Resort.—
Dr. Henry O. Maroy, of Boston, read a paper on this subject.
The higher Alleghanies in western North Carolina were de-
scribed at considerable length as offering mountain health-re-
sorts of a character well suited to a variety of diseases. The
deductions had been based on a long tour of personal investiga-
tion made during the last summer as a sanitary study.
The President's Address : " What is Medicine ? " — At the
evening session the President read his annual address. He said
that the place of the Academy was not to be sought for among
the pathological, clinical, sanitary, and other national associa-
tions. It antagonized none of these, but sought to cement all
into a compact unity. One of the reasons of its slow growth
was the restriction of membership to graduates in medicine who
had received degrees in letters. As the co-operation of every
educated man interested in the objects of the Academy was de-
sirable, the time had come when every»limitation to fellowship
should be removed except the solitary requirement that the can-
didate should be in fact, as in title, " learned in medicine," and
in all else that this term implied ; but he would make it impossi-
ble for any one unfit or unworthy to enter, though h« came with
an armful of diplomas and had subscribed to the most inflexible
of codes, and no matter what faculty, society, or institution he
might be delegated to represent. A second reason why the
Academy had not met with more pronounced sympathy and sup-
port was its necessarily hostile attitude to institutions and indi-
viduals who defied the principles of its constitution. It encoun-
tered a third obstacle in the lukewarmness of its quasi-friends,
some damning it with faint praise, others being exuberant in
private but chary of public indorsement. Let us ask ourselves
the question, " What is medicine ? " It was the most profound
and ennobling study that could engage the intellect of man. This
was not the popular idea, which was that medicine was only
something in a box or bottle, that was prescribed by a man or
woman who had acquired more or less skill in administering the
particular remedy appropriate for each disease. Medicine in-
volved the knowledge of everything that related, however re-
motely, to the existence of man, his place in nature, his origin,
growth, development, preservation, and continuance. The pre-
vention and cure of those abnormal conditions which tended to
his destruction were but one chapter in the volume, which, com-
ing near the end, could not be read understandingly without the
thorough comprehension and diligent study of all that preceded.
Medicine was so far-reaching in its sources and so connected
with every other branch of knowledge that he who would begin
its study must first have drank deep of the well-spring of human
knowledge. Medicine was a science of such proportions that
only a well-educated man could master it. Medicine had no
need to rear its superstructure on any other foundation than the
broad basis of fact. It had been dragged down to the level of
commonplace occupations by the dissensions incited by the dog-
mas of theorists. When all physicians stood on the plane of
higher medicine, there would be less tendency to diverge into
extremist classes. Was our estimate of medicine visionary, and
had we sought the impracticable ? Must we silence our voices
because few cared to hear, and cease our efforts because the task
was difficult ? Must we tread the beaten track, lest we offend
prejudices, antagonize pecuniary interests, and upset established
orders? Not on this account should we hesitate, if the truth
was with us. The ethics of medicine rightly denounced fra-
ternity with charlatans and quacks. Was the dishonor less if
we degraded a noble profession by admitting to its rights and
honors those who were ignorant, illiterate, and incompetent?
Thursday's Proceedings.
Medical Education. — The following resolution was adopt-
ed : Resolved, That a committee of three be appointed by the
president, to report at the next annual meeting, to prepare a
statement of the best preliminary education for medical students,
and also a statement of the minimum attainments which medi-
cal schools should require of students before admitting them to
the study of medicine. It was also resolved to appoint a com-
mittee of two to report on the requirements for a preliminary
526
PROCEEDINGS OF SOCIETIES.
[N. Y. Mkd. J oik.,
education of the various medical colleges in the United States
and in Canada.
Officers for the Ensuing Year were elected as follows:
President, Dr. R. Stansbury Sutton, of Pittsburgh, Pa. ; Vice-
Presidents, Dr. Lewis P. Bash, of Delaware, Dr. S. J. Jones, of
Illinois, Dr. K. L. Sibbett, of Pennsylvania, and Dr. F. II. Gerish,
of Maine ; Secretary and Treasurer, Dr. R. J. Dunglison, of
Philadelphia; Assistant Secretary, Dr. Charles Mclntire, of
Easton, Pa. Pittsburgh was selected as the next place of meet-
ing. The time, the third»Tuesday of September, 1886.
Medical Evidence.— Dr. Thomas J. Turner, of the navy,
read a paper which had had its origin in his duty in connection
with the naval retiring board. The positions of the medical mem-
ber of the board were that of an ordinary witness, that of an ex-
pert witness, and that of a concurrent judge of both the facts
and the law. In the first instance the medical officer made a
physical diagnosis; in the second place he made a rational
diagnosis based upon subjective phenomena ; combining these,
he arrived at a conclusion. On questions of science, skill, art,
and the like, persons instructed on such subject-matters, known
in ordinary language as experts, were permitted, from the neces-
sities of the case, to give "matters of opinion " in evidence;
and, as to the necessity which permitted the introduction of such
opinions, each tribunal determined for itself at the time. Herein
the expert differed from the ordinary witness, who testified as
to " matters of fact." The boundary-line where ordinary testi-
mony ended and expert testimony began was not always well
defined. So far as related to opinions on medical questions, any
one at present might be permitted to testify, the question of the
special amount of knowledge being left to the jurors to deter-
mine. It followed from this that there was no testimony which
varied so immensely as so-called expert testimony. It had been
decided that a medical opinion might be received as evidence
if it was based upon study without practice, or upon practice
without study, and it had been ruled that it was not absolutely
necessary that one should have either studied or practiced medi-
cine. The term expert testimony was somewhat misleading,
and the term "opinion-evidence," as used by Best, was prefer-
able, for opinions might be admitted in evidence by those who
could not be classed as experts. The test of the admissibility
of opinion-evidence seemed to be this: Had the expert witness
auy peculiar knowledge or experience not common to the w orld
which rendered his opinion, founded upon such knowledge or
experience upon the subject-matter under inquiry, of value to
the Court in determining the truth of the matters at issue? The
degree of credence given to opinion-evidence should be founded
upon the professional skill, the quickness of perception, the
powers of discernment, the aptitude, the acquirements, aud the
education, as well as the experience and observation, of the ex-
pert.
A Report on Laws regulating the Practice of Medi-
cine in the United States and Canada, by Dr. Richard J.
Dunglison, of Philadelphia, and Dr. Marcy, was read by Dr.
Dunglison.
From New York it was reported that the act of 1884 had
not been effective in excluding from the profession grossly in-
competent and uneducated men.
Health Officers, Ancient and Modern, was the title of a
paper by Dr. Benjamin Lee, of Philadelphia. In regard to the
organization of boards of health, the first point made was that
in selecting the material, politics, in the bad sense of the term,
should be rigidly excluded. Where it was possible to avoid it,
the members should not be elected by the people, especially in
large cities. Secondly, boards of health should be composed
chiefly of physicians, but at least one member should be a man
eminent among his fellows for prudence and judgment in trade
and commerce, for doctors were proverbially bad business men.
Thirdly, as it was desirable that there should be harmony of
action and of sentiment between the municipal government and
the board of health, there should be a representative of each in
the other. Fourthly, it was essential for the practical working
of the hoard that it should employ a paid agent, who should de-
vote as much time as was necessary to inspection and investiga-
tion ot the sanitary conditions of the locality, and carry into
execution the orders of the board. Finally, every member of
the board should receive a fair and even generous compensation
for his labors.
Micro-organisms and their Relation to Disease was the
title of a paper by Dr. Samuel N. Nelson, of Cambridge, Mass.
Observations on the Relation of Bacteria to Certain
Puerperal Inflammations was the title of the next paper, by
Dr. Ernest W. Cushing, of Boston. He called attention to the
great difference between the customs and rules governing the
obstetric assistants and students in Berlin and in Vienna. In
the former city, every precaution was taken to avoid not only
direct infection, but also any possible carrying of germs in the
hair or clothing, as if bacteria were freely present in the air.
In Vienna, although the possibility was admitted in theory, yet
in practice the assistants and students were allowed to be pres-
ent at autopsies. Obstetric operations and laparotomies were
performed before the whole class, ^without spray, and the chief
assistants gave operative courses on the cadaver every after-
noon, relying for safety on washing, bathing, and change of
clothing. Practically, sepsis arising in the hospital was very
rare, and the results obtained by avoiding direct infection
through the fingers and instruments were regarded by the
speaker as an argument in favor of the view that puerperal fever
was not an entity the poison of which was carried about in the
air and entered the system through the lungs, etc., but was the
result of the invasion and multiplication of bacteria, arising from
infection of the uterus or abraded vagina, as a rule, directly
from hands, instruments, or applications.
In discussing this paper, Dr. R. Stansbury Sutton, of
Pittsburgh, Pa., said that, while there was no question as to
the success achieved by the use of antiseptics in general surgery,
yet in abdominal surgery the best results so far had been ob-
tained by strict attention to cleanliness without the use of any
antiseptic agencies. He agreed with Dr. Cushing that, when
the poison entered the abdominal cavity in laparotomy, or the
vagina or uterus in puerperal cases, the germs were not carried
by the atmosphere, but by the hands, forceps, ligatures, or in-
struments. So far as abdominal surgery was concerned, he
thought that all chemical agents could be discarded, but cleanli-
ness could not be lost sight of.
Dr. Marcy related a case bearing on the introduction of
antiseptics into the peritoneal cavity. It was that of a child
four years of age, whose abdomen was filled with pus, in which
the streptococcus was found. The pus was evacuated and the
peritoneal cavity thoroughly washed out with bichloride-of-
mercury solution. The patient recovered without a bad symp-
tom.
Medical Licenses and Medical Honors was the title of a
paper read by Dr. Edward Jackson, of Philadelphia. A com-
parison was made between the requirements of the medical col-
leges of this country when first organized and the requirements
of to-day, and a gradual lowering of the standard, with a cor-
responding decrease in the honor conferred, was noted. The
speaker thought it doubtful if any system of State license to
pursue any calling should be looked on with favor. If adopted,
it must be removed from all possibility of lowering competition,
and surrounded by every guarantee of honest enforcement which
disinterested examiners and full publicity could give.
Nov. 7, 1885.]
PROCEEDINGS OF SOCIETIES.
527
OBSTETRICAL SOCIETY OF PHILADELPHIA.
Meeting of October 1, 1885.
The President, Dr. B. F. Baer, in the Chair;
Dr. W. H. H. Githens, Secretary.
The Different Forms of Paralysis met with in Young
Children. — Dr. Whakton Sinkleb read a paper on this subject.
He said that the form most frequently met was infantile spinal
paralysis, or polio-myelitis anterior. This term indicated the
pathology of the disease, which was an inflammation of the
nerve-cells of the anterior horns of white matter of the spinal
cord. This affection might come on at any period of life, but
was generally seen in children, and usually at the age of two
years. The children were generally strong and apparently
healthy, and the paralysis was sudden in its onset. Fully two
thirds of the cases he had seen had been attacked in the summer
months, hot weather and teething seeming to be predisposing
agents. Dr. Barton, of Manchester, Eng., reported that, of fifty-
three cases in which he noted the time of onset, twenty-seven
occurred in July and August. The attack was preceded by fever
of greater or less intensity, with pain in the head and limbs,
with general soreness when moved or lifted. After a few days,
paralysis more or less complete occurred, but in a few days a
regression of the paralysis from some of the affected parts oc-
curred. Sensation was undisturbed. Atrophy of the muscles
was soon apparent ; in fact, the paralyzed portion stopped grow-
ing for a time. The temperature of the affected portion was
low and the skin was blue and mottled, but there was no tend-
ency to ulceration, and wounds or scratches healed readily. The
skin and tendon reflexes were lowered or abolished in the af-
fected limbs. At first response to the faradaic current was lost,
and later on the galvanic current produced but little muscular
contraction, except when a powerful current was used. When
atrophy had set in the reaction of degeneration was seen. Most
of the cases of club-foot were the result of infantile palsy. De-
formities of the upper extremities were rare, this disease differ-
ing in this respect from cerebral palsies. The exact causes of
infantile palsy were unknown. Over-fatigue often preceded an
attack; sudden chilling was considered by Seguin to be a fre-
quent cause.
The prognosis as to perfect recovery was only moderately
good. In many cases the most faithful treatment failed to re-
store the paralyzed muscles, but in almost every case we could
expect more or less improvement.
In the early stages of the paralysis, after the subsidence of
the fever, the treatment should consist of mild stimulation to
the spine ; ergot and small doses of bromide of potassium should
be given internally. Later in the disease, iodide of potassium
should be given instead of the bromide. When the palsy was
established, electricity and massage were the means to be de-
pended upon. They must be persisted in for months or even for
years. Internal treatment was of little or no value unless there
was some failure in the general health of the child.
Spasmodic paralysis as seen in children was of two varie-
ties— when of primary spinal origin, or when there was a de-
scending degeneration of the cord from a primary cerebral lesion.
Sometimes there seemed to be a congenital defect in the motor
tracts of both brain and cord. In the spinal variety there was
often seen, soon after birth, rigidity of the limbs ; at first this
was only occasional, but, as the child got older, every effort to
move a limb caused muscular rigidity in it. The child did not
attempt to walk until three or four years of age. Then, when
it was supported under the arms and it tried to stand or to walk,
the movements were very peculiar and characteristic. The feet
were extended and inverted so that the child rested on the toes.
The knees were strongly adducted and locked together so that
the legs became entangled. By degrees the child became able
to walk with the aid of apparatus or some form of crutch. The
hands and arms were often affected and every effort caused
muscular rigidity to come on. The mind was unaffected in
these cases and the speech might be distinct, although it was
often very defective. Sensation was unimpaired and the patella
reflex and ankle clonus were exaggerated. There was no wast-
ing of the muscles. By these symptoms we inferred that the
disease was localized in the lateral columns; but exactly what
was the nature of the lesion we did not know, for no post-
mortem examinations had been made in these cases. The cause
was unknown. Hamilton found three of seven cases which he
had collected were premature births. Adherent and contracted
prepuce had been thought by some to be the cause by reflex
influence of the spasmodic paralysis, but operation had not given
relief. The treatment should consist of massage, galvanism to
the spine, ergot, and cod-liver oil. Fluid extract of conium
might be given to allay spasm. In some cases great improve-
ment followed this treatment.
Even when we could do no positive good to the limbs, very
much could be effected by the aid of apparatus. Properly ad-
justed braces to the legs would enable a child to walk on
crutches or in a Durrach wheel crutch.
There was a form of spasmodic spinal paralysis in which the
child was imbecile. In these cases there had probably been con-
genital defect in cerebral development. The head was small and
there was no evidence of intellect; often nystagmus was present.
Paralysis from Pott's Disease. — Paralysis of the lower ex-
tremities might result from caries of the spine. The lesion
might be either a meningitis or a myelitis. If meningitis alone,,
there was considerable pain and contraction of the legs. Gen-
erally there was a transverse myelitis. The symptoms were
numbness and pricking of the legs, with loss of sensation;
gradually increasing loss of power with wasting of the muscles;
incontinence of fasces with retention or incontinence of urine.
Sometimes there were ulcers over the sacrum or on the limbs.
The indications for treatment were evtflent. An apparatus
which would take the weight of the body from the spine was
necessary, and was sometimes sufficient of itself. Frequently,
however, the application of the actual cautery over the spine
produced improvement in the symptoms when an apparatus had
done no good. Massage and electricity should be used to re-
store the atrophied muscles.
Paralysis from rhachitis and diphtheria was seldom com-
plete. The former was often spoken of as the pseudo-palsy of
rickets. Negro children, who were very subject to rhachitis in
cities, often had rhachitic paralysis. The child at three or four
years was unable to walk or stand. Sometimes it bad not suffi-
cient muscular development to sit upright. It could move every
limb and had no loss of sensation, but had no power. Cod-
liver oil and massage brought about the most satisfactory re-
sults in these cases. Diphtheritic paralysis usually began in the
muscles of the soft palate and pharynx and extended to the ex-
tremities. It was generally bilateral and incomplete, but he
had seen a case in which it was hemiplegia It was considered
peripheral in character and was believed by some to be con-
nected with the altered condition of the blood consequent on
the original attack. Diphtheritic paralysis was rarely fatal and
lasted in most cases only a few weeks, although it might con-
tinue for months. Strychnia and electricity were the means to
be employed, and the case usually responded promptly to these
remedies.
Pseudo-hypertrophic paralysis was a rare affection, but was
of much interest. The disease belonged almost exclusively to
infancy. It was characterized by muscular paralysis with great
528
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jodh.,
increase in the bulk of tbe muscles. This enlargement was due
to fatty deposit, while the muscular tissue proper was atrophied.
The affection began with weakness of the legs, a peculiar bal-
ancing of the trunk, and separation of the legs in walking. The
shoulders were thrown far back in standing and walking. There
was great difficulty in getting from the sitting to a standing
position. Later in the disease the muscles became wasted and
shrunken and the general health began to suffer. Death resulted
from implication of the respiratory muscles. The skin was mot-
tled like a piece of Castile-soap. The tendon reflexes were abol-
ished, and electro-muscular contractility was impaired. There
was often a greater or less amount of mental weakness. There
was no loss of power over the bladder and rectum, and sensa-
tion was not affected. Heredity influenced the disease, which
was slow in its progress, but the course was steadily downward.
Friedreich's disease was still more rare than the preceding.
It was practically locomotor ataxia in childhood. There was
evidenced here also a hereditary predisposition, and the female
children seemed most liable.
Cerebral Palsies. — Hemiplegia might result from some in-
jury at the time of birth, either from the forceps or from the
pressure of a prolonged labor. A child might be born hemi-
plegic after a perfectly natural and easy labor. Under these
circumstances, we must regard the paralysis as the result of im-
perfect cerebral development. Hemiplegia under these circum-
stances was generally permanent. The side affected grew less
rapidly than the other. The flexors of the arm and hand were
usually contracted. The leg became rigid in the act of walking.
Convulsion was almost always associated with cerebral paraly-
sis, either immediately preceding the attack or occurring soon
after. The convulsive movements were most violent on the
side which was subsequently paralyzed. The child would have
an idiotic expression and speak indistinctly, but its friends
thought it intelligent. The convulsions were liable to return
when the child was older and then assume an epileptic form.
The walk was peculiar, and was called the spastic gait. The
patient plodded along looking as if he were about to pitch for-
ward. The affected Jambs were smaller and shorter, the growth
of both bone and muscle being affected. In the choreic vari-
ety, where the arm was in constant motion, the muscles might
become hypertrophied, but the bone remained short.
Prognosis. — As a rule, the prospect of recovery was bad ; even
if the patient got well, the hemiplegic side remained awkward.
Treatment. — Cod-liver oil and massage, which always relaxes
the contracted muscles. The affected limbs should be used as
much as possible.
Dr. Harris inquired if Dr. Sinkler had ever observed any
hereditary predisposition to convulsions and cerebral paralysis.
Dr. Sinkler replied that the hereditary influence was decided
even when no convulsions occurred.
Oophorectomy.— Dr. E. E. Montgomery reported the fol-
lowing case: Mrs. L., of Columbia, Pa., aged thirty-six years,
married ten years, pregnant five times; the last, four years ago,
was brought to his notice by Dr. A. F. Chase. Her health had
been bad since her last confinement. First menstruation at
twelve years and a half, regular and very free for one year and
a half, when she fell, producing pelvic distress, after which for
seven years the flow was very scanty, lasting but one or two
days, and accompanied by excruciating pain. She improved
somewhat after marriage. Her first conception was followed
by so much nausea, vomiting, and ansemia, that her physician
advised and induced an abortion.
She was now regular as to time but irregular as to quantity ;
it was preceded by an excruciating pain for two days and con-
tinued until the flow disappeared ; she also had severe pain in
the head. She was very nervous at all times, but this was
much intensified during the period. Pain was more marked in
the left inguinal region and down the corresponding limb. Coi-
tion and vaginal examination were very painful. The uterus
was enlarged and painful, tender on pressure over both ovaries.
Local uterine treatment had been kept up during the entire four
years with no relief. Trachelorrhaphy had been performed.
Ovariotomy was advised. September 19, 1885, she entered Dr.
Montgomery's private hospital, and, assisted by Dr. W. H. and
Dr. C. B. Warder, and Dr. E. Eshleman, the uterine appendages
were removed. The left ovary was composed of a number of
cysts, the largest of which ruptured while adhesions were being
separated. The right ovary was not enlarged, but it was re-
moved to insure relief. The wound was closed with silk gut
and dressed with sublimated gauze and absorbent cotton. There
was no shock. The highest temperature reached was 101-6° at
midnight of the 20th, and it became normal on the 22d. Sutures
were removed on the eighth day and the wound redressed for
the first time. It had united throughout, and there was no irri-
tation from the suture. The effect upon her general health re-
mained to be determined.
Supra-vaginal Removal of the Uterus and both Ovaries
for Fibroid Tumor. — Dr. Montgomery also reported the fol-
lowing case: Ann U., aged twenty-seven, was brought to him
by Dr. T. H. Boysen, of Egg Harbor City, with the following
history : Her menses from the beginning occurred every three
weeks, and were free an entire week. During the last four
years they had occurred every two weeks, and were attended
with pain in the pelvis and down the limbs, and severe pressure
upon the bladder, causing frequent urination and several times ren-
dering the use of the catheter necessary. Dr. Boysen had diagnos-
ticated fibroid tumor, which Dr. Montgomery's subsequent exami-
nation confirmed. The tumor was the size of a child's head,
filling up the pelvis and apparently arising from the anterior
wall. The examination led him to believe that the bladder was
adherent over the anterior surface, and would render the re-
moval of the tumor unsafe. He suggested the removal of the
ovaries. She entered his private hospital September 15, 1885,
for that purpose. Dr. W. H. Warder, Dr. Boysen, and Dr.
Martin assisted, Dr. C. B. Warder and Dr. Staltweather present.
An incision three inches long was made, and, finding the tumor
free from the bladder, with cervix sufficiently long to serve for
a pedicle, the incision was extended to within an inch of the
umbilicus above and symphysis below, and the tumor, with
some difficulty, withdrawn. In the absence of a Tait's clamp,
which had been ordered some days before, the pedicle was con-
stricted by a wire ecraseur, and the tumor, with the ovaries,
was removed. The pedicle was then transfixed with two steel
pins and tied in three sections with strong silk thread. The
peritonaaum was fastened to the pedicle below the ligatures and
the wound closed with silk-gut sutures, the pins holding the
stump outside. The wound was dressed with sublimated gauze
and absorbent cotton. The operation was followed by some
shock ; temperature 97'4°, pulse 104, from which she soon ral-
lied. She complained greatly of pain. A half-grain of mor-
phia had been given by suppository, and three hypodermatic
injections of morphia, one quarter of a grain each, were given
during the afternoon, before tbe pain was relieved.
At 3 a. m. of the 24th he was called by the nurse, who re-
ported bleeding from the stump. Three ounces of blood had
been lost. By aid of Dr. Warder, a Wells's clamp was applied
below the pins, apparently controlling the hemorrhage; but it
recurred later in the day from the angles and from beneath the
clamp. By this time the Tait's clamp had arrived, and the pa-
tient was etherized, the lower three sutures removed, the pedicle
drawn up, the clamp applied so as to control it completely, and
the wound again closed. The wound had united throughout.
Sov. 7, 1885.]
REPORTS ON TEE PROGRESS OF MEDICINE.
529
Temperature reached 100-6° at 9.30 p. m. The highest subse-
quently, 10T6, was in the afternoon of the 25th, and it became
normal on the 28th. Upon removing the dressings on the 27th,
some pus welled up about the pedicle. As the skin was irri-
tated, the dead pedicle was cut away until the clamp slipped off.
There resulted, of course, considerable retraction of the stump,
-but the sloughed tissue was nearly cleared away. The patient
suffered no pain or discomfort ; temperature normal. The tumor
was situated in the anterior wall and fundus of the uterus, and
projected into the uterine cavity.
Dr. Parish remarked that removal of the ovaries had given
such good results in cases of uterine fibroids, and was compara-
tively so free from danger, that he would like to hear from Dr.
Montgomery his reason for his choice of operation.
Dr. Montgomery replied that the tumor filled the pelvis
and pressed upon the bladder and rectum, causing great and
•constant distress. As diminution of the size of the fibroid tumor
was not a certain result of oophorectomy, and as all the cir-
cumstances were in favor of the major operation, he decided
upon it as the best one.
Imports on % ^rogrtss of l$etru*we.
OTOLOGY.
By CHARLES STEDMAN BULL, M. D.
The Effect of Sounds upon Diseased and Healthy Ears. — Roosa
r" Ztsehr. f. Ohreuheilk.") draws the following conclusions from his
■observations : 1. Many persons, who in quiet places suffer from deaf-
ness, hear readily during or in the midst of a loud noise. 2. The dis-
ease in such cases is situated in the middle ear, and is of the chronic,
non-purulent variety, though it may be an acute catarrh, and even a
chronic purulent process with partial loss of the drum-head. 3. The
cause of this phenomenon probably depends on an altered action of the
ossicula. 4. The acuteness of hearing of laborers in a boiler-shop
steadily diminishes. 5. The disease produced by this occupation lies in
the labyrinth or trunk of the acoustic nerve. 6. These patients do not
hear better in a noise, but their hearing is better in a quiet place, and
improves by absence from the source of injury which causes the deaf-
ness. 7. The cases of hardened wax and catarrh of the middle ear
occurring in boiler-makers resemble those met with among other labor-
ers ; they mask and complicate the original disease known as " boiler-
makers' deafness." 8. In disease of the labyrinth or acoustic nerve the
tuning-fork C is heard louder and longer by air-conduction than by bone-
conduction.
The Production of Artificial Deafness, and its Relations to the
JStiology and Development of Ear Disease. — Cassels (Ibid.) formulates
three theories as to the aetiology and development of disease of the ears :
I. A certain degree of tension of the drum-head is necessary to a perfect
functional act of the drum-head. 2. The essential cause of all disturb-
ances of hearing depends upon an alteration in the normal tension of
the drum-head. 3. All pathological symptoms in ear disease are devel-
oped in regular succession. As a result of his experiments in the pro-
duction of artificial deafness, he considers that when three of the ordi-
nary symptoms of a disease of the ears may be produced by an experi-
ment within a few minutes, and in the order of succession in which they
appear in the natural way in disease, the assumption is justified that, if
this- experiment were continued for hours or days, these symptoms
would be further developed and might produce complicated tissue
changes.
Caries of the Petrous Bone, with Paralysis of the Facial Nerve and
Fatal Haemorrhage from the Carotid, — Moos and Steinbrugge [Ibid.),
la a report of such a case, call attention to the rapid development of the
caries, within a period of four months. There was total destruction of
the cells of the mastoid process. They regard it as doubtful if such
an extensive sclerosis could develop in so short a time along with the
carious process, and think it probably began a year earlier — at the time
of an attack of typhus fever from which the patient had suffered.
Perforation of the Mastoid Process. — Hartmann (Ibid.) gives the
results of this operation in fourteen cases, and lays down rules for its
performance. 1. The incision in the skin and the opening in the bone
should be made in the line of attachment of the auricle to the bone or
immediately behind it. 2. The wound should not be made farther up-
ward than the level of the upper wall of the auditory canal. 3. The
wound should be sufficiently large to admit of perfectly seeing the bone
and carefully treating it. 4. The wound must be kept open until the
bottom has become filled by concentric granulations. 5. All secretions
or cholesteatomatous masses must be carefully and thoroughly removed,
and the walls of the wound and bony canal must be filled with powdered
iodoform.
Pyaemia in Acute Suppurative Inflammation of the Middle Ear. —
Hessler ("Arch. f. Ohrenheilk.") here gives the results of five autopsies
of cases of suppuration of the middle ear, which he had taken frorrl pub-
lished reports of cases. In the first case there was acute caries of the
walls of the tympanic cavity, but the left transverse sinus was empty.
In the second case the transverse sinus contained a pulpy, degenerated,
and completely decolorized thrombus, which extended into the bulb of
the jugular vein. In the third case there was caries of the walls of the
tympanic cavity, with pus between the dura mater and tegmen tym-
pani, but no thrombi in the lateral sinuses. In the fourth case the
brain substance and ventricles were normal, and there was no sign of
caries in the petrous bone in situ. In the fifth case there was no
change in the brain and sinuses, but the middle ear was filled with
thick, offensive pus. In all these cases the patients had suffered from
symptoms of pyaemia. He cites in detail a case of his own, occurring
in a boy, aged twelve, in whom the pyaernic symptoms were pronounced,
but the boy subsequently recovered. From the results of the autopsies,
it seems probable that the pyaemic poison in the blood in affections of
the ear may reach the circulation not only by means of the sinuses, but
also by phlebitis of the small veins in the bony walls of the tympanum
and mastoid antrum.
Gumma of the Auricle. — Hessler (Ibid.) reports a very interesting
case of this rare disease in a man aged twenty-four. There was par-
tial necrosis of the cartilage of the auricle resulting from an ulcerating
gumma, which had existed for several weeks. This suppurated for
several days at a time, and then the discharge ceased. The right auri-
cle was very much swollen, bluish in color, and stood out straight from
the head. The tissues over the mastoid were markedly swollen. Upon
the anti-helix was an ulcer, 3 mm. in diameter, with yellow margin and
base, and a dirty serous discharge. The external auditory canal was
narrowed, but the glimpse of the drum-membrane that could be ob-
tained through the lumen showed it to be normal. The hearing power
was undiminished. The initial lesion had probably occurred four years
previously. The case was at first treated by cauterizations with silver
nitrate and simple lead-washes, and each application of the caustic was
followed by enormous swelling of the auricle. At a later visit, the
whole substance of the auricle round the ulcer was found undermined,
and the cartilage found necrosed throughout a considerable extent.
Large doses of potassium iodide brought about a complete cure in less
than two months.
The Temporal Bones of Two Deaf-Mutes. — Moos and Steinbrugge
("Ztsehr. f. Ohrenheilk.") here gives the results of a very careful mac-
roscopic and microscopic examination of four temporal bones removed
from the bodies of two deaf-mutes. The following conditions were
common to the labyrinths of all four bones : 1. The absence of nerves
in the lamina spiralis ossea of the first whorl of the cochlea ; in the
upper whorls of both cochlea? of the second case there were still some
nerve-fibers present. 2. The arrest of development and atrophy of the
ganglion-cells within the canal of Rosenthal. 3. The defective devel-
opment and fatty metamorphosis of the organ of Corti. 4. The filling
of the ductus cochlearis in one case, and of the scala vestibuli in the
other case, with a caseous mass of material intimately by coagulated
lymph. 5. The occurrence of hyaline masses in various parts of the
membranous labyrinth. In the left labyrinth of the second case there
was also found a membranous and osseous coalescence of the tissues
of the first portion of the first whorl of the cochlea in the scala tvm-
530
MISCELLANY.
[N. Y. Med. Joi r.,
pani ; and in the first case the nerve-epithelium and nerves in the left
sacculus were wanting.
The Employment of Calomel in the Treatment of Otorrhoea. —
Gottstein {Ibid.) speaks highly of the local employment of calomel in
chronic suppuration of the middle ear; when combined with the mer-
curic bichloride, he regards it as more valuable and prompt in its action
than boric acid. He assumes that when calomel conies in contact with
fluids which contain sodium chloride, such as pus, the mercuric bichlo-
ride is formed ; this has a powerful antiseptic action in itself, and in a
state of nascent production this action is probably more energetic. He
has employed calomel in a large number of cases ; has found it abso-
lutely non-irritating to the mucous membrane of the middle ear ; it
never forms any deposits upon or ia the mucous membrane which are
difficult of removal, and the results of its action are sometimes surpris-
ing. He recommends that the ear should be washed out with a weak
sublimate solution (0-1 per cent.); then the ear should be inflated by
Politzer's method, so as to drive all secretions into the external audi-
tory canal, and these should be removed by another injection. The
canal is to be thoroughly dried with cotton and filled with pow-
dered calomel by means of a powder-blower, and stopped with cot-
ton. This method of treatment may be employed even in the begin-
ning of acute inflammation of the middle ear. By reason of its marked
insolubility, it always remains finely pulverized and does not clog the
powder-blower. Gottstein regards calomel as a much surer and more
powerful antiseptic agent than boric acid. The secretion in these puru-
lent cases diminishes within a few days after the commencement of the
calomel treatment, and no adverse symptom has ever been noticed from
its employment. In some cases Gottstein has employed a mixture of
powdered calomel and common salt, and discovered that this mixture
was mildly corrosive. He employed this powder in cases of otorrhoea
with extensive perforations and swelling of the mucous membrane of
the middle ear. The powder causes a slight pain for a few minutes,
and the secretion is temporarily increased. The next day there may be
seen a thin, grayish-white slough upon the mucous membrane. When
this slough comes away the powder is insufflated again.
The Diagnostic Value of the Relation between Air-conduction
and Bone-conduction. — Brunner's investigations upon this subject
{Ibid.) are of considerable interest and importance, and are given as
follows: 1. Under normal conditions the air-conduction overbalances
bone-conduction, so that the vibrations of a tuning-fork are heard
longer and louder through the air than through the medium of the mas-
toid process. 2. In pure diseases of the external and middle ear,
where the deafness has reached a certain degree, the reverse is the case
as regards air- and bone-conduction. 3. Neither theoretical specula-
tion nor clinical observation makes it probable that bone-conductibility
may be strengthened or increased by pathological processes in the laby-
rinth or acoustic nerve. 4. Hence it is proper to infer, from the dis-
tinct overbalance of the latter, the existence of a constant disturbance
in the sound-conducting apparatus, which, by resonance or hindered
sound-exit, favors bone-conduction over air-conduction. It must be
remembered, however, that the aurist has often to deal with mixed dis-
eases, in which it is necessary to clearly understand the relations of
air-conduction to bone-conduction. One of the questions to determine
is whether in nervous deafness the expected overbalance of air-conduc-
tion might, by simultaneous anomalies in the sound-conduction (such as
impacted cerumen), be changed into an overbalance of bone-conduction,
and vice versa. Another point for consideration is the possibility that
in an affection of the sound-conducting apparatus (such as middle-ear
catarrh) the expected overbalance of the bone-conduction might be
weakened or entirely abolished by a simultaneous complication in the
labyrinth. This leads to the question whether the overbalance of bone-
conduction always presupposes a more or less intact perception. In
these mixed cases two factors are to be considered: 1, the factor
which increases bone-conduction by resonance, which is by no means of
equal importance in all affections of the sound-conducting apparatus ;
and 2, the factor which diminishes the bone-conduction caused by an
affection of the nervous apparatus. One source of error which must
be remembered and avoided is that the relation between bone-conduc-
tion and air-conduction, even in the normal ear, is not the same for all
ttining-forks, since low-toned forks are more strongly and readily per-
ceived through bones than the high-toned forks. Brunner thinks that
there is no doubt that at the entrance of the cochlea in the lowest whorl
the actual or innate power of irritation of the terminal nerve-apparatus
is much greater than in the upper whorls.
Surgical Meteorology. — According to Dr. B. W. Richardson (" As-
clepiad "), the time is favorable for operation : a. When the barometer
is steadily rising, b. When the barometer is steadily high. c. When
the wet-bulb thermometer shows a reading of five degrees lower than
the dry-bulb. d. When, with a high barometer and a difference of
five degrees in the two thermometers, +here is a mean temperature at
or above 55° F. The time is unfavorable for operation : a. When the
barometer is steadily falling, b. When the barometer is steadily low.
c. When the wet-bulb thermometer approaches the dry-bulb within two
or three degrees, d. When, with a low barometrical pressure and ap-
proach to unity of reading of the two thermometers, there is a mean
temperature above 45° and under 55° F.
The University of Pennsylvania. — The Medical Faculty has issued
the following circular :
" The passage of the law of 1881, entitled ' An Act to provide for
the registration of all practitioners,' etc., placed the Medical Faculty of
the University of Pennsylvania in a very embarrassing position. It had
no knowledge that the act was before the Legislature, so that no op-
portunity was afforded of considering it. Hitherto, with great hesita-
tion, the Faculty has issued certificates as to the genuineness of the
diplomas possessed by applicants, and these certificates have been ac-
knowledged by officers of registration. It is, however, evident that, in
doing this, the Faculty has not complied with the law which requires it
to be ' satisfied as to the qualifications of the applicant,' and it is very
doubtful whether the certificates which have been given legally entitle
their recipients to registration. During the last few months it has be-
come more and more apparent that the University of Pennsylvania, if it
continues to grant certificates as to the genuineness of diplomas, must
issue such certificates for the diplomas of all sorts of colleges. The
genuineness of the diploma is in no way dependent upon the scientific
character of the body issuing it. A diploma is genuine if the body
from which it emanates has a legal right to issue such diploma, and, if
the law is to be interpreted by the University as requiring its faculty
simply to testify as to the genuineness of a diploma, it can make no
difference whether such diploma is issued by a regular or irregular col-
lege. Further, the gradations between colleges in this country are so
close as to make the drawing of lines a task of great difficulty, and the
Medical Faculty can not set itself up as a judge between colleges, and
say that the diploma of this suffices and that does not. A very serious
matter is the fact that these certificates issued by the University are
looked upon by persons ignorant of the circumstances — i. e., by the gen-
eral community — as indorsements of the medical qualifications of their
possessor, and as being in some measure tantamount to the diploma of the
University. When the ease with which genuine diplomas are obtained
in America and the little significance which so many of them have are'
remembered, it becomes evident that the issue of these certificates by
the University is an injustice to its own graduates. The Medical Fac-
ulty also feels that the qualifications of applicants can only be deter-
mined by examination, and that it is not legally justified in issuing any
certificates whatever, unless ' satisfied as to the qualifications of the ap-
plicant.' It, of course, believes that no one is qualified to enter upon
the practice of medicine who can not pass the examinations required
from students of the University. It therefore proposes hereafter to
exact such examinations from applicants. In the future, all persons
desiring from the University of Pennsylvania the indorsement on the
diploma demanded by Section 4, of the Act of 1881, will be required to
pass an examination on chemistry, anatomy, physiology, materia medica
and therapeutics, pathology and morbid anatomy, practice of medicine,
surgery, and on obstetrics ; failure in any branch will cause rejection.
To compensate for the labor of such examinations, a fee of $30 will be
charged."
Nov. 7, I885.J
MISCELLANY.
531
The Jtemains of Harvey. — In our issue for November 10, 1883,
we published a letter from London, describing the ceremonies connected
with the transfer of the remains of William Harvey from the dilapidated
feaden envelope in which they had lain for more than two centuries to
a sarcophagus provided by the Royal College of Physicians. At the
Hempstead Church before the Accident.
same time, October 18, 1883, the remains were transferred from the
vault of the church to the Harvey Chapel above. All was done that was
then possible toward providing the remains with a proper resting-place.
There is still left, however, the restoration of the church itself to
be accomplished. The church is situated in Hempstead, a small and
obscure village in North Essex, where the Harvey family settled. About
three years ago the tower fell and reduced the building to a ruin. Its
former appearance and its present ruined state
are shown in the accompanying views, which
are reproduced from the London " Graphic."
• It appears that the parishioners are too
poor to provide the entire funds needed for
the restoration of the church, and a committee
of our professional brethren in England have
very properly taken in hand the task of rais-
ing the necessary amount. Sir Henry Pitman,
M. D., Royal College of Physicians, Pall Mall
East, London, S. W., who is the treasurer of
the committee, has^ issued a circular briefly
setting forth the facts, and stating that " any
contribution will be thankfully acknowledged."
It is for the purpose of bringing the mat-
ter to the attention of American physicians
that we have written this notice, and we be-
lieve that many of them will be glad to con-
tribute something toward the performance of
a duty that the medical profession of the
whole world owes to the memory of the dis-
coverer of the circulation. The publishers
of this journal will take pleasure in forward-
ing any contributions that may be sent them to the treasurer of the
London committee, and all sums received will be acknowledged in these
columns.
The Scope of Laws regulating the Practice of Medicine.— Dr. C.
N. Metcalf, the secretary of the Indiana State Board of Health, having
addressed a number of queries to the Attorney-General, Mr. Francis T.
Hord, in regard to the interpretation which should be put upon some of
the provisions of the Medical Act, those queries, together with the At-
torney-General's replies, have been printed, and we are indebted to Dr.
James Bradwell, of Indianapolis, for a copy of the document, from
which we quote as follows :
" Q. 4. — ' Does the statute apply to a person who undertakes to cure
diseases by manipulating the patient's body, by rubbing, kneading, and
pressure ? '
"A. — The statute applies to persons desiring to practice medicine
surgery, and obstetrics only, and it ought not to be so construed as to
cover persons not substantially within its
terms. (Smith vs. Lane, 24 Hun., 632. Wert
vs. Clutter, 37 Ohio St., 347-352.) In Wert
vs. Clutter, supra, the Court says •: ' This stat-
ute was not intended to create a right in any
one to practice medicine. It was simply in-
tended to prohibit the exercise of the right
(which before was universal) by unqualified
persous. The right remains in all persons,
except those from whom it is taken away by
the statute.' In Bibber vs. Simpson (59 Me.,
181) suit was instituted for $51 for services
rendered the defendant's intestate, at his spe-
cial request, by the plaintiff as a clairvoyant.
It appeared from the plaintiff's testimony that
she professed to be a clairvoyant ; that when
asked to examine the patient she saw the dis-
ease and felt as the patient did ; that sittings
or seances were of different durations, from
one quarter to one half of an hour each ; that
she did not pretend to understand medicine
or anatomy ; that she was requested by the in.
testate to visit him and render him profes-
sional services, and did so as by the account ; that she helped him, but he
died from taking cold ; acquainted him with the prices, and he agreed to
pay them, but never did. Appleton, C. J., in deciding the case, says:
' The services rendered are medical in their character. True, the plaintiff
does not call herself a physician, but she visits her sick patients, examines
their condition, determines the nature of the disease, and prescribes the
remedies deemed by her most appropriate. Whether the plaintiff calls
The Kuins of Hempstead Church.
herself a medical clairvoyant, or a clairvoyant physician, or a clear-see-
ing physician, matters little; assuredly, such services as the plaintiff
claims to have rendered purport to be, and are to be deemed, medical,
and are within the clear and obvious meaning of R. S., 1871, c. 13, sec.
8, which provides that " no person, except a physician or surgeon, who
commenced prior to February 16, 1831, or has received a medical de-
gree at a public medical institution in the United States, or a license
from the Maine Medical Association, shall recover any compensation
for medical or surgical services, unless previous to such services lie had
obtained a certificate of good moral character from the municipal offi-
cers of the town where he then resided." The plaintiff has not brought
532
MISCELLANY.
[N. Y. Mkd. Jopb,
herself within the provisions of this section, and can not maintain this
action.' In Smith vs. Lane (24 Hun., 632), Daniels, J., says: 'The
action was brought to recover the price which it was alleged the de-
fendant agreed to pay the plaintiff for the treatment of himself and
wife for certain bodily disabilities. It consisted entirely of manipula-
tions with the hands. It was performed by rubbing, kneading, and
pressure. The evidence given by the plaintiff was to the effect that he
was employed by the defendant to perform these services for a specific
compensation, and that he had performed them until the amount due
him was the sum of $149. Upon the close of the case on his part, the
referee dismissed the complaint because it appeared that the plaintiff
was not a graduate of any medical school, and had no license permit-
ting him to practice either medicine or surgery. The direction was
given because of the prohibition contained in Chapter 436 of the laws
of 1874, and, as no other reason appeared in the case, or the evidence
which was given that would prevent the plaintiff from recovering, and
whether this act contains anything subjecting him to such disability, is
the only substantial point which requires to be considered in the case.
The statute in terms merely declared it to be a misdemeanor for any
person to practice medicine or surgery who is not authorized to do so
by a license or diploma from some chartered school, State board of
medical examiners or medical society, or who shall practice under cover
of a medical diploma illegally obtained, and for the purpose of qualify-
ing a person neither licensed nor possessing a diploma of the nature of
that mentioned to practice medicine or surgery, it was provided that
he should obtain a certificate from the censors of a medical society
either in the county, district, or State, in which it should be set forth
that he had been found qualified to practice all the branches of the
medical art mentioned in it. It appears to be quite manifest that the
object of the Legislature in the enactment of this chapter was only for
regulating the practice of medicine or surgery, as those terms are usually
or generally understood, and, confining them to such significance, it is
evident that they would not include the occupation of the plaintiff.
The practice of medicine is a pursuit very generally known and under-
stood, and so also is that of surgery. The former includes the applica-
tion and use of medicines and drugs for the purpose of curing, miti-
gating, or alleviating bodily disease, while the functions of the latter
are limited to manual operations usually performed by surgical instru-
ments or appliances. It was entirely proper for the Legislature by
means of this chapter to prescribe the qualifications of the person who
might be intrusted with the performance of these very important du-
ties. The health and safety of* society could be maintained and pro-
tected in no other manner. To allow incompetent or unqualified per-
sons to administer or apply medical agents, or to perform surgical
operations, would be highly dangerous to the health as well as the lives
of the persons who might be operated upon, and there is reason to
believe that lasting and serious injuries as well as the loss of life have
been produced by the improper use of medical agents and surgical im-
plements and appliances. It was the purpose and object of the Legis-
lature by this act to prevent a continuance of deleterious practices of
this nature, and to confine the uses of medicine and the operations of
surgery to a class of persons who, upon examination, should be found
competent and qualified to follow their professional pursuits. No such
danger could possibly arise from the treatment to which the plaintiff's
occupation was confined. While it might be no benefit, it could hardly
be possible that it could result in harm or injury, and for that reason
no necessity existed for interfering with this pursuit by any action on
the part of the Legislature. His system of practice was rather that of
nursing than of either medicine or surgery. No bodily disability or
diseases could either result from" or be aggravated by the applications
made by him, and what he did in no just sense either constituted the
practice of medicine or surgery. He neither gave nor applied drugs or
medicine, nor used surgical instruments.'
" It is my opinion that our statute is susceptible of the same con-
struction expressed in said case of Smith vs. Lane, and that our statute
does not cover the person embraced by your question, and that he is
not required to procure a license."
The Health of the State of New York. — The State Board of Health's
" Monthly Bulletin " for September gives the total reported mortality
as 6,251, the percentage of infant mortality being 37. In each 1,000
deaths there were 134'22 from diarrhceal diseases, 23'20 from typhoid
fever, 141 '74 from consumption, and 76 from acute respiratory dis-
eases.
The New York Physicians' Mutual Aid Association will hold its
annual meeting on Thursday, the 12th inst., at 4 o'clock p.m., at the
hall of the Academy of Medicine. A revision of the by-laws will be
proposed by the Board of Trustees, and a full attendance of the mem-
bers is desired.
THERAPEUTICAL NOTES.
Dover's Powder and its Modifications. — Dr. B. W. Richardson
(" Asclepiad "), after giving in brief the history of a case of " septinous
pneumonia " (a term which he applies to pneumonia " induced by in-
haling some toxic product from a cesspool "), says that in cases of that
sort there is no such anodyne, no such soporific febrifuge, as Dover's
powder. If he could envy any one as a therapeutist, he says, it would
be the old physician who originally had the happy thought of blending
astringent opium with relaxant ipecac, and both with a diuretic and laxa-
tive. He thinks it is often very good practice to modify Dover's powder
by combining the one grain of opium and the one grain of ipecac w ith
other salines than sulphate of potassium. True Dover's powder, he con-
tinues, contains the nitrate as well as the sulphate of potassium — four
grains of each in ten grains of the compound — and it often seems to
him reasonable to revert to this form, nitrate of potassium, in small
doses, being a good diuretic. He also often ventures upon other modi-
fications : in acute rheumatic fever he usually substitutes sodium salicy-
late for the potassium salt ; in gout, bicarbonate of sodium ; in remit-
tent febrile cases, two grains of quinine with five of sodium salicylate ;
and in quinsy and other febrile throat affections, chlorate of potas-
sium.
The Therapeutic Value of Chloride of Calcium.— Dr. R. W. Crigh-
ton (" Practitioner ") considers this salt of special value in the treat-
ment of scrofulous affections of the glands, and thinks it has an altera-
tive action in all forms of the strumous diathesis. He uses the crystal-
lized chloride, as the anhydrous salt forms a turbid solution and has an
unpleasant taste. He gives one, two, or three grains at a dose to young
children, and rarely over twelve or fifteen to adults. The dose of Cog-
hill's solution (five ounces of the crystallized salt to twelve fluidounces
of syrup) varies from five to forty minims, according to age and other
circumstances. He always gives it in milk, after meals.
Nitrite of Sodium in Gouty Epilepsy. — Dr. J. M. Granville (" Brit.
Med. Jour.") thinks that epilepsy is often of gouty orfgin, especially in
female members of gouty families, and in such cases he has produced
highly satisfactory results with the following formula :
Sodium nitrite ^ 36 grains ;
Sodium hippurate 3 drachms ;
Infusion of serpentaria to 12 ounces.
Two tablespoonfuls to be taken three times a day, before meals. The
author says that the dose of sodium nitrite may be increased by one
grain after each fit that occurs after the treatment is begun, until the
dose of fifteen grains is reached. The mixture should be taken for three
or four months.
The Action of Quinine on the Foetus. — Vadenuke (" These inaug.
de St. Petersb. " ; " Arch, de toco].") arrives at the following conclu-
sions : 1. Quinine taken by the mother passes into the system of the
foetus in the proportion of about one ninth of the whole amount. 2.
The largest amount is contained in the foetus at the end of two hours.
3. The foetus eliminates it in a little more than forty-eight hours, and
the neonatus in seventy-two hours. 4. Large therapeutic doses, given
to the mother, do no harm to the foetus. 5. The same is true of large
doses repeated every forty-eight hours. 6. Quinine is not an aborti-
facient. 7. It may ward off abortion or premature labor when the
mother is under the influence of fever, especially of malarial origin.
A Mercurial Soap, made by triturating equal weights of mercury and
a perfectly neutral olive-oil-and-potash soap, is highly recommended by
Dr. P. Spillmann, of Nancy (" Ann. de dermat. et de syphil."), as a sub-
stitute for mercurial ointment. It keeps well, is not irritating, and can
be washed off from the ekin with simple water.
THE SEW YORK MEDICAL JOURNAL, Novembek 14, 1885.
ctturcs a it tr ^ijbr^ss^s.
MODERN METHODS OF TREATMENT OF
PULMONARY PHTHISIS.
BEING A CLINICAL LECTURE
DELIVERED AT THE BELLE WE BOSFITAL MEDICAL COL-
LEGE, OCTOBER 27, 1885.
By BEVERLEY ROBINSON, M. D.,
CLINICAL PROFESSOR OF MEDICINE.
Gentlemen : The subject of my lecture before you to-
day is to me a most interesting one. It is especially attrac-
tive because I believe, by the general adoption among prac-
titioners of medicine of the means to be referred to, a posi-
tive and great benefit may be afforded to a vast number of
individuals who are now sufferers from an otherwise almost
hopeless disease. Let me say to you at the beginning of
my remarks, so as to avoid any possible misapprehension,
that I am of the opinion at the present time, just as much
as ever before, that all usual means of treatment in pulmo-
nary phthisis which have been proved to be practically use-
ful are none the less advantageous because something newer
and further can be added. By all means advise your phthisi-
cal patients to observe strictly well-determined hygienic rules,
to breathe, habitually, if possible, a high, dry, pure, equable
atmosphere ; give them cod-liver oil, as much as they can
properly digest and assimilate; let all undue mental and
physical fatigue be eliminated, if it may be, from their daily
existence ; locate them in large, sunny, well-ventilated apart-
ments ; see to it that their food and drink are nutritious and
suitable — in short, do whatever you can to retard the march
of disease in the lungs, or to promote and obtain absolute
cure. Admitted, then, that this plain duty is set before us ;
admitted that what our classical text-books teach is sound
doctrine and should be unerringly followed, still may we
not go beyond their teachings and try new methods which
reason encourages and clinical observation and experience
obviously support ?
The answer is evident. The three methods, then, to
which I call ybur attention, taken in the rank of what I
believe to be their relative importance, are :
1. Increased alimentation.
2. Continuous antiseptic inhalations.
3. Intra-pulmonary injections.
One of the symptoms most to be dreaded in the course
of pulmonary phthisis is anorexia. When this condition is
insurmountable, the patient's future is well-nigh hopeless
Food must be taken, so as to preserve life. But at times
the repugnance to food is so great among phthisical pa
tients that they turn from it in sheer disgust. No matter
how temptingly the dish is prepared, there still remains the
inability to swallow it. Now, then, how can the appetite be
awakened, especially when its complete absence is already
feared at an early stage of pulmonary phthisis? Of course,
we may and should first try the different vegetable bitters,
combined, or not, with an acid or an alkali; but if these
fail, and very often they will, despite our best-directed en-
deavor, what then shall we do?
Under these circumstances, and in view of what my
reading and personal experience show me, I now recom-
end washing out the stomach by means of a soft-rubber
tube connected with a funnel. After a very short period —
sometimes within a few days from the time daily washing
is begun — the patient will gladly say that his appetite is al-
ready much improved. Take another instance — that, for ex-
ample, of a patient whose appetite is not good, it is true,
but who, nevertheless, forces himself to eat, and who, within
a few minutes or hours after food is taken voluntarily,
vomits it up. How are such patients to be treated? As I
have said in regard to my first example, by washing out the
stomach daily until stomachal tolerance is, at least, acquired
for easily assimilable food. Further, there is a class of
cases in which the anorexia is only moderate and the power
of digestion for food not completely lost. Of course, it is
au effort to eat, and there is certainly no desire for food.
Besides, soon after food is swallowed the patient suffers
from weight or pain in the stomach, acid eructations, or ex-
treme flatulence, which are about equally unpleasant and
render the patient unwilling to eat unless forced to do so
by his own convictions or the urgent appeals of friends.
Manifestly in these instances the patients do not take suffi-
cient food, or do not assimilate it well enough to huld their
own, far less to repair the daily damages that are effected
by the wasting disease of which they are victims. Here
again I counsel daily washing of the stomach. In the be-
ginning I do not advise so-called forced feeding by means
of the soft-rubber tube. I believe it is wiser in many in-
stances to wait some days before commencing alimentation
in this manner; still there are exceptions. In certain cases,
even after repeated washing of the stomach, the patient will
be unable to retain food after swallowing it. He may feel
that he needs food, and he may be perfectly willing to take
it, and yet every time he attempts to swallow even a few
mouthfuls the food is almost immediately rejected by an
effort of retching or vomiting.
Singular to say, the mere act of swallowing appears
sometimes to occasion the subsequent feeling of nausea and
vomiting. If we introduce food into the stomach with the
stomach-tube, even in tolerably large quantities, the food
is retained. And not only is it retained, but it is digested
and assimilated, and the patient soon feels better and
stronger. And with the repeated administration of food in
this manner the appetite returns by degrees and in a rela-
tively short time, and the stomachal digestion continues
daily to improve. After the lapse of several weeks, a
month or two, or perhaps longer, daily washings of the
stomach are no longer necessary. These may be repeated
at longer intervals, finally to be stopped altogether. In
regard to the forced feeding it is somewhat different. The
rule is to super-aliment if possible — to give the patient
more than he can possibly crave or desire, to make him
digest and assimilate more food than he would be willing
to, or indeed could, swallow. Now, this may be accom-
plished by pouring into his stomach once, twice, or even
three times a day milk ; milk and eggs ; milk, eggs, and beef
peptonoids, in smaller or larger quantity. The main indi-
534 ROBINSON: MODERN METHODS OF TREATMENT OF PULMONARY PHTHISIS. [N. Y. Med. Jodb.,
cation is, after all, to stuff the patient to his or her utmost
capacity, short of causing actual distress or incompetence
on the part of the digestive organs. It is, again, a remark-
able fact that, within an hour or two after the time when
a pint or more of milk, two or three eggs, half to an ounce
of beef peptonoids have been poured into the stomach of a
phthisical patient, he or she will have quite as good appetite
as, if not better than, there would have been if no nutriment
had been taken. When this forced alimentation, together
with the regular daily meals, has been continued for some
days, the patient's weight will commence slowly to increase.
And, so far as his general condition is concerned, it will
be manifestly improved. While this is true, and although
flesh and muscular vigor are both obviously on the increase,
the intra-pulmonary condition will remain absolutely sta-
tionary. It may also progress slowly or rapidly. It may,
fortunately, become retrogressive and markedly improved.
An instance of the former kind was fully reported by me
last June at a meeting of the American Laryngological As-
sociation, and I do not wish at the present time to repeat
this history. I have not been able to bring before you to-
day a case of pulmonary phthisis in which washing the
stomach and forced alimentation are being carried out,
although I have two such cases (in women) under my care
now at St. Luke's Hospital. In place of cases of phthisis
being thus treated, and in order to show you the ease and
effectiveness of the plan of forced alimentation, allow me to
present to you this man. The patient, J. P., is forty years
old, single, and a cigar-maker. He has suffered for a
long while from asthma, that followed a bronchial attack
which occurred during the war of the Rebellion. He has
had dyspepsia during three years, which has frequently been
accompanied by vomiting of very offensive liquids. Occa-
sionally he has felt much depressed, and even ill, from the
repetition and severity of these paroxysms. All the food
he ate lay like a dead weight on his stomach, or gave him
intense pain. His power of digestion seemed completely
gone, and he suffered continued misery unless he recurred
almost daily to the use of purgative pills. In this case the
stomach-tube was first used on October 22, 1885, and the
stomach washed out thoroughly with warm water slightly
alkalinized by means of borax. After the first washing,
twenty-two ounces of milk were poured into the stomach
and easily retained. The operation of washing and feeding
with the tube has been repeated twice since until to-day
(October 27th), and to the milk two or three eggs have
been added. Already the patient affirms, as you hear, that
he has now no pain in his stomach after eating, that food
does not lie as a load in his epigastrium, and his appetite
has improved. Yesterday he ate and digested some meat
without difficulty, which is the first experience of this kind
he has had during several months.
Now, then, what this man states I have heard repeatedly
before, and had several like cases under my care at differ-
ent times. For your benefit I will now show you how
easily my patient swallows his tube, how easily his stomach
is washed out, and how acceptable milk received into his
stomach through the tube appears to be. A word or two
before I leave this subject in regard, 1, to the apparatus em- I
ployed ; 2, to the best manner of using it. Simple instru-
ments are often the best, and so it is in this instance. The
instrument I show you is, in my opinion, the best one for
combined washing and feeding with which I am acquainted.
There are several others, invented or modified by different
physicians, each one having its special advantage, perhaps,
but each somewhat complicated; at all events, none quite
so simple as the one here shown, which to all intents is lit-
tle more than a long rubber flexible tube with a vulcanite
funnel at one end. To be more particular, I would add
that the stomach-tube is similar, except for increased caliber
and length, to those made by Tiemann or Ford for catheteri-
zation of the urethra. This one is twenty-eight inches long
and about one third of an inch in diameter. It is connected
at its proximal extremity by means of two inches of (/lass
tubing with a soft rubber tubing of similar size five feet in
length. This latter piece of tubing is terminated by a fun-
nel. The stomach-tube may be dipped into warm water
before passing it in order to lubricate its surface, or make
its passage easier. It is then introduced in the median
line beyond the base of the tongue, and the patient is told
to swallow. At each repeated effort of deglutition the
catheter is pushed farther on until from eighteen to twenty-
one inches are introduced. We are then quite sure the
tube has penetrated into the stomach beyond the "eyes"
by which the food pours into the stomach. So soon as this
is accomplished, we raise the funnel to a suitable height —
usually the level of the patient's head is sufficient — and pour
into it slowly water of about blood-heat, or a little warmer,
with the addition of borax. The proportion of the latter
may be one drachm to two quarts of water. When we
have poured about a pint of fluid into the stomach, or
when the patient himself makes a sign, or says that his
stomach feels distended, we quickly lower the funnel near
the floor while pinching the soft tube near the funnel with
the index-finger and thumb of the right hand so as to retain
fluid in the entire length of the tube. So soon as the fun-
nel is lowered into an empty receiving-vessel on the ground,
pressure on the tube is relaxed and the water containing the
washings from the stomach is siphoned off. After repeated
washings, or until the stomach is quite clean and the water
comes away clear, we pour in the alimentary substances in
the same manner we did the hot water for washing. In
withdrawing the stomach-tube we should do it quite rapid-
ly, in order to avoid possible rejection of the food. We
should also pinch the tube near its proximal extremity in
withdrawing it so that none of its contents will fall upon
the carpet or floor. Of course it is understood that the
daily washing of the stomach should take place in the
early morning, or at a time when it is comparatively or
entirely free from food ; otherwise the tube is liable to
be choked up by bits of undigested food. Besides, such
pieces may be rejected alongside the tube, and possibly be-
come impacted in the larynx or trachea, causing symptoms
of asphyxia. Whenever it is inconvenient to perforin the
washing at a very early hour in the morning, the patient
may be allowed some peptonized milk, and the washing
may then be delayed for an hour or two. After a certain
number of washings the patient himself may be able to
Nov. 14, 1885.] ROBINSON: MODERN METHODS OF TREATMENT OF PULMONARY PHTHISIS.
535
accomplish this little feat quite as well as the doctor. As
regards the mere passage of the tube, he frequently learns
how to introduce it with greater ease to himself than the
physician can command, and, while introducing the tube,
is perfectly able to make a passing intelligible remark or
two.
We now come to the second part of our lecture, viz.,
the subject of Continuous Antiseptic Inhalations. This,
gentlemen, has been a subject which I have studied very
attentively during the past two or three years. I have ex-
amined many different kinds of oro-nasal inhalers, but I
know of none so simple, so cbeap, and so effective as the
one I have in my hand. These inhalers were originally
made in London, and sold by Squire. I imported a large
number of them for use at the New York Hospital in the
out-patient department, and, within a brief period, finding
them so useful, I have requested Mr. Ford, of Caswell,
Hazard & Co., to manufacture a lot for sale to the public
generally. The inhaler itself is nothing but a simple sheet
of light zinc perforated with numerous small holes and
bent into a somewhat pyramidal shape of suitable size to
cover the nose and mouth. The apex of the pyramid —
which is the part of the inhaler farthest separated from
the mouth and nares — contains a small sponge, held in place
by thread, upon which the inhalant is poured. The inhaler
is held fixed before the nose and mouth by two light elastics
which go around the ears. I have employed at different
times a large number of inhaling fluids and many different
combinations. The fluid and combination to which I now
give the preference is creasote and alcohol, equal parts, to
which I also frequently add a like proportion of spirits of
chloroform. This combination is certainly very useful in
allaying cough and modifying the quantity and quality of
the sputa in pulmonary phthisis. I therefore recommend it
very warmly. The alcohol is added to the creasote for the
double purpose of diluting it and making it more volatile ;
the spirits of chloroform are added, in view of the expe-
rience of Dr. Cohen, of Philadelphia, to diminish local irri-
tation and excessive cough. The inhaler must not be worn
too long at first, nor should too much fluid be poured on
the sponge at any single time. In either event, instead of
giving relief, disturbance is caused ; the throat is rendered
more irritable, and the patient complains of increased sore-
ness and tightness in the chest. Properly and judiciously
employed, the creasote inhalant relieves symptoms notably,
and in the beginning, at least, of pulmonary phthisis is, I be-
lieve, a means of decided utility so far as the possible arrest
of the disease is concerned. It is important that beechwood
creasote be employed. At first the inhaler should be worn
ten to fifteen minutes every two or three hours ; afterward,
it may be worn half an hour or an hour at a time, or even
longer. When the length of time is gradually increased,
only positive benefit will result. From ten to twenty drops of
fluid should be added to the sponge at any one time. If more
is added, it will cause undue irritation. The fluid should
not be poured on the sponge more than two or three times
in twenty-four hours. Precisely the way in which creasote
is most useful is perhaps difficult to state. By its antiseptic
action it is possibly destructive of bacilli ; by its local ac-
tion and general effect it is certainly of value in combating
catarrhal conditions. Where purulent cavities exist it tends
to destroy or neutralize putridity. These are certainly suf-
ficiently good reasons for its use without pursuing the in-
quiry further. At all events, these inhalations do good.
The physician notices it and the patient affirms it. Tn
many instances they allay cough better than any cough-
mixture, and they are certainly free from the great objec-
tion of destroying appetite, as opium and morphine so fre-
quently do.
We now come to the third and last topic of to-day's
lecture, and that is, The Utility of Intra-pulmonary Injec-
tions in Pulmonary Phthisis. I for one, gentlemen, believe
they do good. I also believe they rarely do any harm.
They may occasion localized pleuritis, slight haemoptysis,
or cutaneous emphysema — but that is about all. They cer-
tainly allay cough, diminish the quantity and change the
character of the sputa, and, in some remarkable manner,
have at times manifest power in lessening the distressing
symptom dyspnoea. This method of treating lung-cavities
was first employed in this country by Professor Pepper in
18*74; since that time, and except by Dr. Pepper himself,
I am not aware that any one but myself has practiced these
injections any considerable number of times.- I have now
made between forty and fifty intra-pulmonary injections, and
am disposed to continue them in favorable cases. Of course
it is often a difficult thing to follow up any particular line
of treatment in private or hospital practice, on account of
the prejudices or fears of patients. Thus it is with intra-
pulmonary injections, and in a sitnilar degree, perhaps, with
forced alimentation, already fully described. Whenever
this little operation can be performed, it is, in reality, a very
simple matter.
The point of a fine cannulated needle should be inserted
in the first, second, or third intercostal spaces anteriorly, or in
the axillary region. While there is no risk in making injec-
tions upon or outside of a vertical line passing through the
nipple on either side, there is danger in injecting at any
measurable distance within this line for fear lest we pene-
trate the pericardium, or one of the great thoracic vessels.
The needle should be inserted from two and a half to three
inches. Of course, if considered necessary, the slight pain
of the puncture may be annulled by the use of local anaes-
thesia. I have made use of iodine usually in my injections,
and am how employing a solution of the compound tincture
of the strength of one part to four parts of distilled water.
From ten to twenty minims may be injected upon each oc-
casion, and the injection may be advantageously repeated in
four or five days. Previous to the introduction of the
needle of the Pravaz syringe the patient fully expands his
lungs, and retains the air in them during the few moments
it takes to make the injection. Slight or moderate cough,
some expectoration, streaked or not with blood, may follow
the injection, and for a day or two there may be slight lo-
calized pain in the region where the injection was made.
Further than these symptoms, little or no reaction accompa-
nies or follows the injections. In many cases, as in that of
the man whose chest I have just injected for the third time
within ten days, there is no reaction whatsoever at the time
536
JOES SON:
PARALYSIS OF THE LARYNX.
[N. Y Mel.. Jontc.,
of the injection, inasmuch as he does not even cough. I
I have told you this patient has a cavity at the right apex.
One of the gentlemen wishes to know how I am assured
that the point of my needle has penetrated the cavity. The
answer is very simple ; by giving a slight movement in dif-
ferent directions to the body of the syringe we can readily
appreciate whether or not the point of the needle encoun-
ters any resistance, or is perfectly movable in an empty
space, or one only partially filled with semi-fluid material.
But, presuming for a moment that I can not be always con-
fident that I have struck the cavity, does it matter? Practi-
cally, and according to me, no. That is to say, if you fear
any bad results simply because the injection has been made
into solidified tissue about the cavity. Indeed, I am more
and more convinced that the best indication for these in-
jections is in cases where the apices are solidified and not
softened. I am borne out in this belief by my own expe-
rience. I have already injected in nearly as many caSes of
phthisical infiltration at its first stage as at a later period,
and I have ordinarily seen apparent benefit result. As to
the slight accidents that do occur, they can be easily allayed
by an anodyne, external irritation of the chest, or rest in
bed for a day or two. Of course, when we inject a cavity
we have distkict objects in view, and, if we do not reach
the cavity, we fall short of doing what we purposed to
do. These objects are mainly to disinfect the sputa and
to modify the walls of the cavity so that it will, little by
little, tend to close up and cicatrize, and, in producing this
result, we shall also expect the amount and character of the
secretions from the lung-cavity to be sensibly changed for
the better. When we inject solidified lung-tissue, we ex-
pect something very different. If there is an underlying
inflammatory cause in very many cases of phthisis, and I
still believe there is, we shall modify this inflammatory
exudation considerably. We shall, perhaps, produce such
changes in it as to render it fluid and easier of resorption
or expectoration. As to the influence of iodine or other
injections on the growth or vitality of bacilli, I have yet
no very positive and determined views — any more, indeed,
at this moment, than I feel perfectly sure in regard to the
real, active role of the bacillus itself. Only a few months
ago the chorus of the supporters of Koch was somewhat
after this fashion :
" What is consumption ? The bacillus.
What is the bacillus ? Consumption.
But what causes consumption ? Why, the bacillus.
But what causes the bacillus? Consumption."
And now I ask, in the words of Professor Loomis,
" whether they [these microbes] are the cause or the scaven-
gers of disease ? "
Clinically, of one thing I am quite confident, viz., intra-
pulmonary injections of iodine benefit phthisical sufferers.
Why not, therefore, give them the opportunity of the treat-
ment, and await patiently the auspicious day when even
changing theory may be wholly favorable to their use.
In conclusion, let me urge upon you all to earnestly
consider the facts brought to your attention in this lecture.
It is a subject pregnant with the most vital interest. Our
hospitals and dispensaries show a fearful death-rate from
phthisis. Ordinary methods of treatment are confessedly
disheartening by reason of their very slight influence in
arresting the march of a dread disease, when, moreover, the
odds are, for other and manifest reasons, many against the
poor sufferers.
I have studied with you a series of topics which makes
me more hopeful of what I may be able to do for the arrest
or cure of pulmonary phthisis. In this line of research may
all of you find renewed courage and conviction. Perhaps
some one among my hearers may yet discover the " arcana "
of science in its conflict with this destroyer of our fel-
lows.
(Original Communications.
PAEALYSIS OF THE LARYNX;
WITH REPORTS OF THIRTY-TWO CASES*
By H. A. JOHNSON, M. D., LL. 1).,
CHICAGO.
The following cases are presented with the thought that
they may be useful in future studies. Only what seemed to
be the essential facts have been transcribed from my note-
books. I have no theories to suggest, but leave the record
for the interpretation of those who may be interested in this
class of derangements of the larynx. I have not included
cases in which the derangements depended upon tumors, ul-
ceration, and other structural alterations of the organ.
DISTURBANCES DEPENDING UPON HYSTERICAL CONDITIONS.
Case I. — H. B., female, single, aged twenty-four. No change
in the form or structure of the larynx. The vocal bands in the
cadaveric position. Health in other respects fair, menstruation
normal, appetite good. Was put upon iron, strychnine, etc., and
advised to live as much as possible in the open air. I also ap-
plied the faradaic and galvanic currents, the latter interrupted.
None of these measures produced any change in the function of
the organ. After several months she went East, and finally to
Europe, where she consulted a great number of laryngologists,
with always the same suggestion of strychnine, electricity, and
tonics.
These were tried with the thought that possibly under new
conditions and in more expert bands they might be successful.
After visiting California and the southern portions of our own
country, she went to Europe again, spending a winter in Egypt.
On her return she was under the care of Dr. Hughlings Jack-
son, of London, who had the good fortune to hear her speak
after about five years of silence. During three years of this
time she did not even whisper. The cords remained as de-
scribed till her return from Dr. Jackson. At that time she
occasionally spoke aloud, but only a part of the time. Upon
examination, I then found that in the effort to phonate the
vocal processes were brought together, but there was a triangu-
lar opening back of their points — in other words, there was a
paralysis of the arytsenoids, leaving a space through which the
air escaped, making phonation laborious and at times producing
complete aphonia. From that time to the present, now several
years, there have been periods, for several days and occasion-
* Read before the American Larvngological Association, June 24,
1885.
Nov. 14, 1885.J
JOHNSON: PARALYSIS OF THE LARYNX.
537
ally tor a week or more, that she could not speak nbove a whis-
per. She is and has always been fairly nourished, but of a lym-
phatic temperament, and is easily fatigued. I have repeatedly
examined the larynx during the last few years, and have never
found any changes except as above stated.
That this was a ease of hysterical aphonia 1 presume no one
will for a moment doubt. The interest consists in the fact that
the trouble continued so long and resisted all treatment till seen
by Dr. Jackson.
Dr. Jackson's treatment did not in any essential respects
differ from that which had already been tried. There could be
found no evidence of those perturbations of the uterine or other
organs which generally accompany these cases. I have said
that I presumed this would be admitted to be a case of hysteria.
I use the word not in the strict sense of uterine irritation, but
for that class of neuroses generally grouped under this name.
Case II. — Mrs. F., aged thirty, married, has had for the last
eighteen months some difficulty in speaking, and for the last
four months she has been completely aphonic. There has been
occasionally dyspnoea, but this has seemed to be asthmatic
rather than due to laryngeal stenosis. She has also been under
treatment for some uterine trouble. Examination of the lungs
reveals some vesicular emphysema; heart weak, but no mur-
murs; larynx normal inform and color; vocal cords immovable
in the cadaveric position. There were no evidences of central
trouble nor of any lesion along the course of the nervous
trunks. The patient was sent to me by a gynaecologist with the
query as to the reflex nature of the laryngeal difficulty.
Case III. — T. II., aged twenty-three, female, single. Nine
months ago she took cold; is now aphonic; is short of breath
upon exercise ; emaciated. Physical examination of chest re-
veals no evidence of disease of the lungs or heart. She is emo-
tionally depressed. Menses have not appeared for the last five
months. No fever or other derangements to suggest organic
troubles elsewhere. Tops of the arytaenoid cartilages slightly
swollen; no loss of motion of abductors; right cord does not
come quite to the median line in the effort to phonate; it is
lax, sagging, and hanging away from its fellow. This case seems
to me to be a paresis of the right thyro-arytenoid and probably
also of the right crico-tbyroid, hysterical in origin.
Case IV. — M. C, aged seventeen, female, single. Was never
strong. Has always been subject to colds and throat trouble.
Had diphtheria four years and a half ago; had suppuration of
the lymphatic gland3 of the neck seven or eight years ago; is
now in school, but devoting herself mainly to instrumental
music; is fairly nourished, but has dysmenorrhcea and signs of
ovarian irritation ; no lung or heart trouble.
Upon effort at phonation, the cartilaginous glottis is open ;
in oilier respects movement of the parts is normal. Says that
she formerly was in the habit of singing, but was obliged to
abandon all efforts to sing because, as she expressed it, her
" voice rattled." There may b^ a doubt as to the aetiology of
this case. The patient had diphtheria four years and a half
before the consultation.
Case V. — A. P., aged twenty-five, female, married. Has been
aphonic for the last five months. Was referred to me by a
gynecologist. Has laceration of the cervix ; has now an acute
inflammation of the pharynx and larynx ; the vocal cords are in
abduction and immovable. No evidence of any central or local
laryngeal lesion to account for the paralysis.
Catarrhal.
Case VI.— E. B., aged sixteen, single. Has several times
during the last eighteen months lost her voice, being able to
whisper only. This has usually been treated by her physician
by local applications of argent, nit., thirty grains to the ounce,
and in a few days she has recovered. I find thickening of the
mucous membranes above the glottic chink, and in normal ef-
forts at phonation the false vocal bands approximate so as to
come in contact, shutting oat the view of the true cords. In
easy respiration the vocal processes are nearly in contact. There
must be some paresis of the abductors. The patient was under
the care of a physician in a neighboring city, and I learned that
she entirely recovered with no other treatment than that men-
tioned. The health was in every other respect good. The im-
pairment seemed to be the result of acute catarrh.
Case VII. — J. C, aged thirty-eight, male. Three months
ago was taken suddenly with hoarseness after getting wet.
Very soon afterward the voice became extinct. This condition
has continued to the present time. General health in every
other respects good. No history of specific disease.
Vessels of the larynx large. Secretions excessive. Left vocal
band in efforts at phonation remains midway between adduction
and abduction. Motions -of right band normal. The inter-
rupted galvanic current was applied with an immediate im-
provement. The patient soon passed from my observation.
The only cause that seemed probable was a catarrh from the
cold.
TYPHOID FEVER.
Case VIII. — M. A., aged twenty-nine, female. Had inflam-
mation of the lungs when a child. At the age of twenty had
typhoid fever. Soon afterward the voice began to fail. Was
unable to sing. Two years ago became very much frightened
by an accident, and for two weeks was completely aphonic.
Has been hoarse the most of the time since, except when
aphonic for ten weeks about a year ago. For the last few
weeks has had pain in the larynx and the left side of the chest,
running through to the back. No chest trouble. No uterine
or ovarian difficulty.
In efforts at phonation the vocal bands remained lax, al-
lowing the air to be expelled between .them without the pro-
duction of sound. The muscles involved seemed to be the
crico-thyroids. A marked improvement took place under treat-
ment by the faradaic current.
Case IX. — B. B. B., male, aged fifty-five. Thirty years ago
had typhoid fever. After convalescence, became suddenly
hoarse and then aphonic.
This condition continued eighteen months, when he recov-
ered the use of the voice. Since then has had, when fatigued,
and especially "after speaking for a while, a sense of fatigue,
which he locates in the supra-sternal region. When eight years
old commenced the use of tobacco. Much of the time for forty
years he smoked twenty-five cigars daily. Stopped on account
of a heart difficulty. Has now post-nasal catarrh. There is also
dysphagia, apparently from want of action of the constrictors.
The surfaces of the pharynx are very tolerant to mechanical
interference. The patient is well nourished, weighing 180
pounds. The action of the kidneys normal. No lung trouble.
No organic heart trouble.
Chronic catarrhal inflammation of the larynx. At time of
examination, no derangement of motion.
The case is presented for the reason that the patient
had just recovered from typhoid fever when the aphonia
occurred, lasting eighteen months. The excessive use of
tobacco for so long a time in connection with anaesthesia of
the pharynx gives additional interest to the history.
SYPHILIS.
Case X. — M. L., aged forty-two, female, married. Has had
for eight years some difficulty in swallowing solid food. Says
that six months ago ''something broke in the throat." Says
538
JOHNSON: PARALYSIS OF THE LARYNX.
[N. Y. Med. Jouh.,
that the matter discharged from the throat at that time was
not pus, but a " glairy, transparent fluid ; it was like the white
of an egg." Since then she has been able to swallow better,
but there is now constant dyspnoea. This is especially marked
when asleep, or when fatigued, or excited during the day. The
difficulty is mainly in inspiration. Expiration is easy. General
health is not good. Has a family history of cancer and con-
sumption. There was no evidence of thoracic trouble and no
history of specific disease.
Examination revealed paralysis of the abductors of both
vocal cords. There were no evidences of disease along the
course of the nerve-trunks, so far as I could find. I sug-
gested tracheotomy as a measure of prudence, and ordered pot.
iod., with the thought that there might have been a specific
intoxication. The subsequent history is unknown to the re-
porter.
Case XI. — D. M., aged forty-seven, male. Had syphilis
eight years ago. Six months ago began to have some trouble
with the throat. Voice hoarse, but not lost. Secretions of
pharynx and larynx increased. Health in other respects fair.
Chronic inflammation of the mucous surfaces of the larynx.
Top of left arytenoid cartilage swollen. Left vocal band near
the median line, and does not move upon deep inspiration. Right
band normal in movement.
I am not quite sure that this is a case of paralysis ; it
may be an ankylosis of the cartilage.
Case XII. — E. G., aged forty-six, male. Had syphilis in
early life. Has had cough and difficulty of breathing for several
years. This difficulty came on gradually. It was more marked
when asleep than when awake. The appetite is good. No
lung trouble. Heart sounds normal. No disease along the
pneumogastrics or recurrents. So far as I can ascertain, there
are no secondary or tertiary symptoms of syphilis, unless this
laryngeal disorder be of that character.
Examination reveals a bilateral paralysis of the abductors
of the vocal bands. During phonation the bands become
normally tense, separating slightly at the cessation of the act
of speaking. There did not appear to be any mechanical fixa-
tion of the arytaenoids. The quality of the voice is little, if at
all, affected. Soon after the first consultation tracheotomy was
performed for the relief of a dangerous dyspncea which oc-
curred during the night. The patient was put upon constitu-
tional treatment, with the thought that it might be syphilitic in
origin. No benefit resulted from these measures, and he has
worn a cannula now about four years. I am still inclined to
think that the case is specific.
Case XIII. — D. M., aged forty-seven, male; had syphilis
eight years ago. Six months ago began to be hoarse. The
voice is now rough, but not lost. Health in other respects good.
Secretions of the pharyngeal and laryngeal mucous mem-
branes excessive in quantity. Top of left arytenoid cartilage
swollen. Left vocal band near the median line, and does not
move upon efforts at phonation or deep inspiration. Right
band normal in movements.
It is possible that this is a case of ankylosis of the car-
tilage. The patient was put upon the use of iodide of
potassium.
DISEASE OF CENTRAL ORIGIN.
Case XIV. — M. E. P., aged forty-two, male. Never sick
till four months before consultation. While on the plains in
western Kansas or eastern Colorado he suddenly became apho-
nic. There was no cause to which lie attributed the loss of the
power of speech. After a few weeks he partly, but not entirely,
recovered, and this improvement was followed by complete
aphonia, which has continued to the time of consultation. Gen-
eral health good. No evidence of any thoracic trouble.
Epiglottis pendulous, omega-shaped. Right vocal band nor-
mal in movement. The left is drawn close to lateral wall of
larynx, so as to be seen with difficulty as a line in the mucous
tissues. Upon efforts at phonation there is not the slight-
est movement of the band. Under the influence of the inter-
rupted current there was a slight change of position. Surface
of larynx hyperaasthetic. Subsequent history of case unknown.
Case XV. — P. D., aged sixty-five, male. Five years ago
had an injury from a fall, striking upon the right shoulder. Ten
days afterward began to have difficulty in speaking. For three
weeks could not make himself understood. Has not been able
to speak easily since. Now there is something like stammering.
There has never at any time been loss of consciousness, nor is
there now any impairment of the intellectual functions. The
arm and leg of the right side are weaker than those of the left.
No deformity of the face or want of co-ordination. Bowels
regular. The urine passes slowly. Has been treated during the
last live years by various methods, including the use of electrici-
ty. Thinks nothing has done him any good. The appetite is
now fair; sleep not good. Has headache every day.
Mucous membrane of the larynx slightly injected; otherwise
normal. Movements of the left side of the organ very slight.
In efforts to phonate, the right arytamoid cartilage is carried
beyond the median line, its apex drawn forward of the apex of
the left. The edge of the right band is higher than that of the
left, and is also carried beyond the median line.
What is the explanation of the paresis of the right side
of the trunk and extremities, and the left side of the larynx ?
Case XVI. — V. P., aged thirty-six, male. During the last
two years has had at times a dull post-sternal pain. This has
not been constant in character. Has never been sick since
childhood till the commencement of the present trouble. There
is no pain in the throat, nor is there constant dyspncea, but
within the last three months there has been shortness of breath
upon taking exercise. Speaks now with difficulty; the voice is
rough. Of late there has been slight dysphagia. Within the
last few weeks there has been some numbness of the left leg.
No perversion of the special senses and no ataxia. In other
respects the patient seems well. Physical examination of the
chest reveals no lung trouble, and I can find no evidence of
aneurysm.
Left vocal cord nearly immovable in the cadaveric posi-
tion. No other alteration of the organ. At a subsequent ex-
amination there was the same condition so far as the motions
of the parts were concerned. But there was in addition a
marked anaesthesia of the mucous surfaces. The dysphagia was
increased, and the laryngeal muscles on the left side did not
respond to the faradaic current.
Case XVII. — R. W., aged forty-eight, male. Not strong as
a child. Had "brain fever" when twenty-one years old.
Never had syphilis. About one year ago began to have dys-
phagia. It came on suddenly, and gradually increased during
the year. Five weeks ago attacked with dysphonia. This also
came on suddenly, and has remained without change to the
present time. Was subject to headache for several years before
the commencement of the present troubles. Not so much since
the advent of the dysphagia a year ago. Has, however, fre-
quent attacks of neuralgia of the right side of face and head.
No evidence of lung or heart trouble.
Right vocal band immovable near the median line. In other
respects the organ is normal. Can see no evidence of any dis-
Nov. 14, 1885.]
JOHNSON: PARALYSIS OF THE LARYNX.
539
ease along the course of the nerves. The headache, neural-
gia, difficulty of swallowing, with the "brain fever," all point
to some central lesion.
Case XVIII.— E. N., aged fifty-four, male. Has had for the
last ten years some discomfort in the throat. At times dysp-
noea. During the last year the difficulty of breathing has
been worse, especially upon taking exercise. Seven months
ago had a slight hemiplegia of the right side. Is now able to
use the right arm to some extent. The throat trouble is worse
since the paralysis. Never had any specific trouble. Had ty-
phoid fever twenty years ago. No thoracic trouble, lungs or
heart.
Larynx normal in appearance. Upon effort at deep in-
spiration there is only a narrow opening between the bands.
There is only a very slight movement of the bands in phona-
tion. The paralysis of the abductors is not complete, but
nearly so.
COMPRESSION OF THE RECURRENT NERVE.
Case XIX. — O. A., aged twenty-four, male. Has had some
cough for last six months. A slight haemorrhage occurred
about two weeks before consultation. Evidently deposits in
apex of left lung. There has been for some time impairment
of voice. Upon inspection, the left band is restricted in the
range of movement. No other signs of laryngeal trouble. No
swelling of the cartilages or thickening of the mucous mem-
branes.
The interest of the case consists in the fact of paresis
of the left side of the larynx in connection with tubercular
deposits in the corresponding lung. It is stated by some
authorities that such deposits do, by their pressure upon the
recurrent, produce paralysis. I think it must be very rare ;
but this case seems to justify the proposition.
Case XX. — X. S., aged forty-nine, female. Has been hoarse
for two years. In that time has lost twenty pounds in weight.
Six months ago had rheumatism. No cough. No fever. Ex-
amination of the chest reveals a soft bruit at the outlet of the
left ventricle with the first sound. This is propagated into the
aorta, and heard with great distinctness in the supra-sternal
notch. No evidence of any lung trouble.
Color and appearance of the larynx normal, except that the left
band moves only very slightly. It is very near the median line,
both in inspiration and in phonation. The right in phonation
passes beyond the median line to meet its fellow. There must,
I think, be a dilatation of the arch of the aorta, producing
pressure upon the left recurrent. Saw the patient several
months afterward. Found no material change.
Case XXI. — E. B., male, aged thirty-seven. Has been
hoarse for the last live months. Recently has been troubled
with cough. General health till commencement of this trouble
good. Upon examination of the chest, find aneurysm of the
aorta at the superior and left portion of the arch. No lung
trouble. Paralysis of the abductors of the left vocal band,
which remains in the position of adduction in the median line.
Motions of right side perfect.
Query. — Why is not the left band in the cadaveric position?
Case XXII. — II. S., male, aged fifty-one. Had, four years
ago, a kick from a horse, producing an injury to the back of the
head and the right side of the neck. The wound of the neck
was on a level with the fourth ring of the trachea. The cica-
trix is well marked, and is close to the trachea. Since the
injury he has been hoarse; speaks with difficulty. General
health good.
Epiglottis large, wide, erect. Complete paralysis of the
right side of the larynx. Left side normal.
Case XXIII. — G. T. L., male, aged forty-eight. In early
life was not in good health. Twenty years ago spit blood. For
the last three years has had some difficulty in speaking when
fatigued. This sometimes produced vertigo. Fourteen months
ago had a severe strain of the muscles of the right side of the
neck ; said at the time that he " had broken his neck.''. Eight
months ago began to experience pain in throat, and more de-
cided difficulty in speaking. The voice is now low in pitch and
feeble. No lung or heart disease.
Paralysis of laryngeal abductors of the right side, the cord
remaining in the median line. Left side normal. Why is the
cord not in the cadaveric position? Was there an injury to the
pueumogastric or recurrent at the time of the " strain " ? There
had been some difficulty in speaking before that injury.
Case XXIV. — J. C, male, aged sixty-two. Has had hack-
ing cough for twenty-five years. Became hoarse ten months
ago. For the last six months has been aphonic. There is now
difficulty in swallowing liquids. They pass into the larynx and
produce cough and spasm. Appetite good, bowels regular.
Kidneys normal. Emotionally despondent. Percussion note
normal. Breath sounds harsh; rude over both apices; more
marked in front than in back. Heart sounds normal.
Right vocal band immovable in the cadaveric position. Mo-
tions of left normal.
Case XXV. — T. B. K., male, aged forty. Has always en-
joyed good health till nine months ago, when he fell upon the
right shoulder, upon which, for ten or twelve days, the head
was drawn down. He rapidly recovered, however, and was as
well as ever, except that when he took cold he had a stiffness of
the right shoulder. About five months ago he took a severe
cold, and had a hard cough with expectoration of white mucus.
He recovered from this, and about six weeks ago was suddenly
seized with a violent fit of coughing, and immediately the voice
became rough and hoarse. There was difficult inspiration. The
difficulty was greater while sleeping than when awake. At
times there was spasm, making inspiration very difficult. Never
bad syphilis. Upon physical examination, the lung and heart
sounds were found to be normal.
Complete immobility of the right vocal band in the ca-
daveric position. Left side normal.
UNCLASSIFIED.
Case XXVI. — I/. L., male, aged forty-seven. Ten years ago,
while pitching hay on a very hot day, he took cold. Cough
was severe at the time, and since then he has frequently had
hoarseness and shortness of breath. Now the hoarseness is
constant. He attributes it to the " cold " ten years ago. Never
had any injury along the course of the laryngeal nerves. No
specific history. Is well in every other respect. No lung or
heart disease. Slight anaesthesia of the pharynx and larynx.
Left vocal band immobile in the cadaveric position. In ef-
forts at phonation, the top of the right arytsenoid cartilage
passes in front of the left, and the right band is carried beyond
the median line to meet its fellow of the opposite side.
Case XXVI I. — M. W., female, aged thirty-two. Has a
uterine fibroma. Is now taking ergot. During the last three
months has had a cough. Has now some dyspnoea. Is hoarse.
Speaks with difficulty. No lung or heart derangement, Slight
enlargement of the cervical glands, especially back of the left
clavicle.
Paresis of the abductors and adductors of the left vocal
band. In deep inspiration and efforts at phonation there is
only a very slight movement of the vocal hand.
Subsequent history unknown. I am not certain that
this is not reflex in its origin, but the enlargement of the
540
JOHNSON: PARALYSIS OB' THE LARYNX.
[N. Y. Med. Jode.,
post-clavicular glands on the same side with the affected
cord leaves a reasonable doubt.
Case XXVIII. — E. W., male, aged five years. Well till
eight months ago, when he had an attack of diarrhoea. Soon
after began to be hoarse. About four months before consulta-
tion, became completely aphonic. No dyspnoea or cough ; now
well nourished; complains of no pain nor of any discomfort.
Laryngoscopic examination reveals paralysis of the adductors of
both sides. Electricity was used, interrupted current, with
benefit, before a cure was effected. The case passed out of the
knowledge of the writer.
Query. — What was the nature of the affection ? There
was no cerebral trouble, and I could find no cause of inter-
ference with the function of the recurrents. There was
nothing except the diarrhoea as an antecedent.
Case XXIX. — A. D. B., male, aged twenty-seven. Phona-
tion has been difficult for the last four years. Health in other
respects good. Previous to this, had been in the habit of sing-
ing, and had used the voice a great deal. Upon inspection, there
was seen in the act of phonation, a wide space betweeji the
vocal cords throughout their entire length, including the vo-
cal processes. No other departure from the normal condition.
Query, "Was the trouble the result of the over-straining of
the tensors and adductors? The subsequent history is not
known.
Case XXX. — F. R. C, male, aged twenty-five. Always well
until within the last year, during which he has noticed that he
becomes easily fatigued by speaking. It is for this that he asks
for advice. Says that he is in every other respect well. No
specific history. No lung or heart disease.
A triangular opening in the cartilaginous glottis during
phonation. Can find no cause for the difficulty.
Case XXXI— E. F. D., female, aged thirty-eight. In gen-
eral good health. Ill two years ago, when she had pneumonia.
Since then has been subject to cough. Is now hoarse, and has
dyspnoea upon taking exercise. Complains of post-sternal pain.
No history of any pelvic trouble. Lung and heart sounds nor-
mal.
Upon efforts at phonation there is left a wide triangular
opening in the cartilaginous glottis. Membranous glottis nor-
mal. No thickening of the inter-cartilaginous tissue. Left ven-
tricular band slightly larger than the right.
Case XXXII. — X. M., female, aged twenty-nine. For the
last two years has had cough, with expectoration of moderate
quantity of mucus. No hasmorrhage. Appetite fair. Bowels
regular. Menses normal. No emaciation. Slight dullness at
the left top. Breath sounds rude over the same region. Heart
sounds normal in character, but heard with unusual distinctness
over the left apex.
Membranes and cartilages of the larynx normal. No impair-
ment of sensation. Upon efforts at phonation, a long elliptical
opening is seen between the bands and including the cartilagi-
nous glottis. Both vocal bands are in the same position. Could
find no history or evidence of any trouble along the track of
superior laryngeal nerve.
DISCUSSION.
Dr. Cohen : There is a point in connection with the first case
which is interesting, and that is the difficulty of whispering, or
the inability to whisper. This condition, to which I have ven-
tured to give the term apsithyria (lack of whisper), corresponds
with the word aphonia, or lack of voice. This patient I saw some
ten years ago. She was under the care of a neurologist, who
consulted me on account of her inability to speak and to whisper.
She communicated with others entirely by pencil and paper.
But she used to whistle, and had adopted a peculiar habit of
expressing Yes by one whistle and No by two whistles, and so
on. This showed that the paralysis of the muscles of articula-
tion was not complete. As it was evidently a case of functional
aphonia, I suggested the use of the electric current to the mus-
cles of articulation, with the result of curing her whisper. She
was exceedingly emotional, and the gentleman under whose
care she was put her to bed for some intercurrent complaint, and
sent her abroad, and I never had anything professional to do
with her after that time. I saw her eight or nine years after-
ward ; she was well, married, and the mother of a fine child.
She told me she had never lost her whisper. I have met with
a few other cases in which there was inability to whisper as
well as inability to speak. I do not think there is a real paraly-
sis in these cases — paralysis either of the voice or of speech. I
think we have that, condition in which these patients can not
" will " to speak or can not " will " to whisper — the condition
described by Sir James Paget, of London, in connection with
diseases of the urinary organs. If you can control these pa-
tients, and get them to will to do what they ought to do, you
can cure them. Some cases you have of inability to swallow.
The patients can swallow, but they can not or will not will to
swallow, and you have to manage them by having a skilled nurse
to stand over them, give (hem confidence, and force them to
swallow. I am very glad to see the author has been able to in-
clude in his cases one of extreme abduction of the vocal band.
This will add two more to the cases on record.
Dr. Glasgow : When Dr. Cohen commenced to speak I
thought his case was due to a loss of will-power and not to
an absence of muscular power. We often see these cases, and
we can not always determine whether these persons can speak
or not. It recalls an instance which occurred to me last year
of a patient who was unable to speak, but was able to whisper;
but this also was imperfect. Most of the conversation was car-
ried on in writing. There was absolutely no change in the
muscular powers of the larynx. Everything seemed to be per-
fect, so far as we could see by examination. I dismissed her by
saying she could whisper if she wished to. A cure of this case
was effected by prayer. It was on Thanksgiving Day. I first
saw her in August. The minister prayed that the afflictions of
the family should be taken away, that this daughter should be
relieved from her infirmity, and at the end of the prayer she
spoke. Now, there was a deficiency of will-power, I really be-
lieve, in this case. This case was the sequel of a prolonged
typhoid fever. I should think that weakness of the muscles
followed, and she found a sort of difficulty in speech, and, as it
worked upon her mind, she thought she could not speak. I
had assured her she could speak if she would; and after this I
think she was waiting for nothing but an opportunity. This
prayer produced the opportunity. After the prayer she spoke
well. I do not think it was deficient will-power, but perverted
will-power. I think we see many cases in young women. I
think this explains a good many cases of aphonia without or-
ganic muscular change or action.
Dr. Hooper : I have always thought so-called hysterical
aphonia purely functional. Although the patient is voiceless,
the vocal bands are freely movable, as may be seen by asking the
patient to laugh while being examined with the mirror. The
statistics of the Throat Department at the Massachusetts Gen-
eral Hospital show that unilateral paralysis of the vocal bands
occurs about once in two hundred and fifty cases. In the cases
of paralysis which I have seen, I have never yet heard a patient
with one vocal band immovable who was able to speak in a
clear, natural voice, no matter what position the paralyzed band
might be in. I can imagine, however, that in certain rare in-
Nov. 14, 1885.]
SHURLY: PHTHISIS PULMONALIS IN MICHIGAN.
541
stances, as in one case of Dr. Johnson's, the voice may be good.
I agree with Dr. Johnson in the difficulty of determining the
{etiological factor of many of these cases.
Dr. Rice : In a number of cases of hysterical aphonia seen
lately I have been impressed with the frequency of the inaction
of the transverse or arytsenoidseus muscle. I think this muscle
is more frequently affected than any other in hysteria. This
is frequently seen, too, in acute inflammatory troubles of the
larynx, it being the first muscle affected, and the sole cause of
dysphonin and temporary disability of the voice. There is one
case of hysterical aphonia I will mention, since the cure was so
remarkable. It was the case of a young woman twenty years
of age. She had no constitutional trouble that I remember, and
her general health was apparently good. She had been unable
to speak for five or six months, and I found the loss of voice
was caused by a paralysis of the transverse muscle. She had
been treated by a physician, who used electricity and strychnine.
I was unable to benefit her. I received a letter from her three
or four months after my treatment, in which she stated she had
met with a runaway accident, had been thrown from a wagon,
and since then had spoken perfectly. I saw her a short time
after, and there was no paralysis. Another interesting case to
me was that of a man who had a syphilitic history, and who
was, in addition, phthisical. One of the vocal bands was ulcer-
ated all along its free border; the other much swollen. Both
arytsenoids were in a state of ankylosis, the vocal bands being
in the cadaveric position. The remarkable point about the case
was this : when attempts at phonation were made, there was
apparent a tremendous muscular exertion in the larynx, en-
deavoring to compensate for the non-movement of the vocal
cords. The patient was able to produce a fair voice, husky in
character. This was produced entirely by the approximation
of the larynx above the level of the vocal bands — that is, by the
action of the false cords.
A REPORT ON
THE ORIGIN AND GEOGRAPHICAL DIS-
TRIBUTION OF PHTHISIS PULMONALIS
FOR THE STATE OF MICHIGAN*
By E. L. SHURLY, M. D.,
DETROIT.
Mr. President and Gentlemen : The object of the in-
vestigation upon which this imperfect report is based is to
ascertain, if possible, what, if any, influence is exerted by
strictly telluric environment upon the causation of phthisis
pulmonalis. The aerial and social factors of its aetiology
have been for a long time freely and widely discussed, but
the telluric aspect and geographical distribution, according
to my observation, have received much less consideration,
and perhaps deservedly, although it seems to me that we
have too little knowledge on this point to warrant such a
decision.
Circulars were sent out to the profession of the State of
Michigan asking for data relating to the number of cases of
phthisis pulmonalis which had originated only in the town-
ship or county where the practitioner resided, together
with a statement of the number of such patients who were
known to have hereditary predisposition, and whether pri-
mary or secondary. Although a large number of replies
* Read before the American Climatologieal Association, May 28,
1885.
were received, I regret to say the number was somewhat
less than I had hoped for.
As the number of physicians who keep notes of cases is
small in the aggregate, I endeavored to shape the queries
as concisely as possible, and to ask for so little that almost
any practitioner could fill out the answer from memory and
with the consumption of very little time. To those who
were good enough to reply I feel greatly indebted, and I
believe all who are interested in this subject will also share
in this feeling.
I thought it advisable, even at the risk of wearying you,
to precede the tables with a few extracts from the reports
of Professor Winchell and Dr. Rominger, showing the topog-
raphy of the State.
I am greatly indebted to Dr. A. W. Nicholson, lately of
our State Board of Health, for the general and census
tables, and to Dr. Erwin Wright for the preparation of the
other data in the form presented.
Topography, Hydrography, and Geology.
" The two natural divisions of the State are distinguished
by marked physical characteristics. They are completely
cut off from one another by the Straits of Mackinac. The
northern is rugged, with numerous rocky exposures ; the
southern consists of plains, plateaus, gentle undulations,
and moderate hills, with very few outcrops of rocky strata.
The northern peninsula is a mineral region ; the southern,
agricultural. The climates of the two peninsulas are as
distinct as their location and topography."
" The climate of Michigan, both in summer and winter,
is well adapted to the interests of agriculture and horticul-
ture. Its marked peculiarity is attributable to the influence
of the great lakes by which the State is nearly surrounded.
It has long been known that considerable bodies of water
exert a local influence in modifying climate, and especially
in averting frosts ; but it has never before been suspected
that Lake Michigan, for instance, impressed on the climatic
character of a broad region an influence comparable with
that exerted by the great oceans."
" The influence of the sea in equalizing temperatures
has long been understood. The immunity from unseason-
able frosts secured by bodies of fresh water to localities in
their immediate neighborhood has also been universally
observed ; but the fact that inland lakes of the size of Lake
Michigan exert an ameliorating agency quite comparable
with that of the Atlantic Ocean is something which has
only been brought to light by recent thorough discussion of
a wide range of meteorological data."
Distribution of Precipitation through the Seasons in Percentages of
Total Precipitation.
Spring.
Summer.
Autumn.
Winter.
190
21-0
28-8
22
25-8
28-7
27-3
19
Whole State
238
28-3
27-7
20
It appears that the northern localities experience a some-
what greater liability to dryness in all seasons. It must be
542
SHURLY: PHTHISIS PULMONALIS IN MICHIGAN.
[N. V. Mel. Jocb.,
borne in mind, however, that the percentages given are per-
centages of the seasonable means.
" A general glance at the superficial configuration of the
lower peninsula reveals a surface swelling gently from the
shore toward the interior regions."
" Generally the lake shores are depressed."
" The rise of the peninsula from the level of the lakes is
generally gradual, and in a few places only is it abrupt.
The surface is of an undulating, hilly character; the hills
are rounded, and never attain a very great height above the
surrounding country. The southern peninsula is lower than
the northern. The swell of the land forming the water-shed
of this southern division coincides with a line drawn in a
southwest direction from Port Austin, at the entrance of
Saginaw Bay, to the southwest corner of Hillsdale County,
where it enters the boundaries of the State of Ohio. With-
in tbe limits of Tuscola and Sanilac Counties the known
surface elevation of this water-shed is about four hundred
feet, while in Hillsdale, not far from the southern State
line, some points with an elevation of six hundred feet are
recorded ; but the water-shed is probably not over five hun-
dred feet high."
" This, which may be called the southeastern water-shed,
is not broken through by any of the streams, though deeply
excavated by the Huron River in Washtenaw County."
" The descent from the height of the water-shed to the
lake shore is so gradual that a traveler in crossing the pen-
insula from either lake to the other, if he follows tbe river
valleys, can scarcely perceive it. The northern division of
the peninsula rises to nearly double the height of the south-
ern part ; its surface is more broken and diversified by
steeper ascents from lake to terrace. Its highest points in
the vicinity of Otsego Lake are, according to the records
of the railroad surveys, eleven hundred feet from the lake
level. Otsego Lake lies directly west of Thunder Bay, and
not far from the northern terminus of an extensive high
plateau with undulating surface, and an average elevation
of from seven hundred to eight hundred feet."
" All the rivers of the northern part of the peninsula
have their source within this plateau, which is dotted with
a number of inland lakes, some of which, like Lakes Hig-
gins, Houghton, and St. Helen's, are of large size. The ter-
races by which the descent from the plateau is made form a
succession of broad belts ; their sides are moderately steep
and finely timbered ; the lowest are wider, gradually slant-
ing toward the shore, or overlooking it in bluffs of from
forty to sixty feet."
In some places on the west side the bluffs are from one
hundred to two hundred feet high, and Sleeping Bear
Point, a promontory facing Lake Michigan west of Big
Traverse Bay, is said to have an elevation of five hundred
feet. Opposite this point, twelve miles out in the lake,
the Manitou Islands rise abruptly to a height of two hun-
dred feet above the water. South of the second correction-
line the plateau rapidly declines toward Saginaw Bay. Be-
tween the north and south parts of the peninsula a de-
pressed strip of land extends from Saginaw Bay to the
mouth of the Grand River on Lake Michigan, having rarely
more than one hundred feet elevation.
An astonishing number of smaller and larger inland
lakes are found in every part of the peninsula; all have
crystal-clear water, and the principal supply of the head
branches of our rivers comes from them. The more im-
portant rivers collecting the waters of the western slope of
the peninsula are the St. Joseph's, Kalamazoo, Grand, Mus-
kegon, and Manistee. Tbe three first named have their
sources in close proximity to the elevated lands of Hills-
dale and Jackson Counties.
From the same swell of land the River Raisin emanates,
flowing outward into Lake Erie. The Raisin River enters
the lake near Monroe;. it drains the southern part of Wash-
tenaw County, and draws its branches from a number of
small lakes in the southeast corner of Jackson County
through its main north branch. The south branches have
the drainage of Lenawee County.
The St. Joseph's, Kalamazoo, and Grand Rivers almost
touch each other within the small area of a few square
miles in the County of Hillsdale. The St. Joseph's River
originates in a number of small lakes and marshes in Hills-
dale County, and enters Lake Michigan at the village of St.
Joseph.
The streams which form the head-waters of the Kalama-
zoo River rise in Hillsdale County. The river runs north,
west, and northwest, and falls into Lake Michigan near Sau-
gatuck.
Grand River springs from a few lakes in Jackson Coun-
ty ; it runs north and opens into Lake Michigan near Grand
Haven.
Huron River collects its waters from innumerable lakes
and marshes in Livingston and Oakland Counties, flows
southwest, and at Dexter turns southeast and retains this
direction until it enters the Detroit River in the northeast-
ern corner of Monroe County.
Clinton River drains the eastern part of Oakland Coun-
ty and all of Macomb County, entering Lake St. Clair near
Mount Clemens.
Black River is remarkable for its southern course for
nearly fifty miles parallel with Lake Huron, at a distance of
only five or six miles from it. It begins in the northern
part of Sanilac County, and enters St. Clair River near Port
Huron.
Saginaw River is the receptacle of a whole system of
rivers. By the Tittibawassee River the waters of the north
and west are led into it. The Shiawassee collects from the
south, the Flint River from the south and southeast, and
finally the Cass River brings its waters from the northeast
and east.
The river system of the northern part of the peninsula
consists of the following rivers: Commencing at the south-
east side, wc first find the Rifle and Aux Gres Rivers,
which drain the southeastern shore-belt surrounding the be-
fore-mentioned high plateau. Au Sable River is the next
largest river north of them. It draws its branches right
from the high plateau, and drains Otsego in the north end
of it.
Thunder Bay River, opening into Thunder Bay, spreads
its arms north, west, and south, reaching the foot of the
high plateau. The Cheboygan River on the north of the
Nov. 14, 18H5.]
SnURLY: PHTHISIS PULMONALIS IN MICHIGAN.
543
peninsula forms the outlet of three large lakes — Black,
Mullet, and Burt. These lakes are fed by rivers of good
size. On the west side of the peninsula two large rivers
deserve to be mentioned.
Manistee River originates very near the head-waters of
the Au Sable River on the east side. Its mouth is at Man-
istee.
Muskegon River is larger than Manistee ; its branches
extend to the top of the central high plateau, and are fed
by Higgins and Houghton Lakes. Of all the rivers men-
tioned, none are navigable. The water-power afforded by
these rivers is ample, and those the branches of which flow
through timbered lands are of vital importance to the lum-
ber business as mediums for the transportation of felled
timber from otherwise almost inaccessible parts of the in-
terior to ports or railroad stations.
Relief Features in the Lowee Peninsula.
Northwestern
slope.
Southeastern
water-shed.
SOUTHERN LOBE.
Livingston Summit 350
Ingham Summit 391
Grand Ledge Summit 250
Barry Summit 250
Kent Summit 213
Oshtemo culmination 349
Cassopolis culmination 384
{ Oakland Summit 539
Washtenaw Summit 394
J Francis County Summit 411
. Somerset culmination 600
Hillsdale
Summit.
feet.
Cass Summit.
Cambria culmination 613
California culmination 546
NORTHERN LOBE.
Roscommon Summit 820 feet.
Clare Summit (central water-shed) 750 "
Ogemaw Summit 850 "
Southern Division.
Crawford Summit 700 "
Wexford Summit 700 "
Osceola Summit 700 "
Northern Division.
Oscoda Summit 800 "
Otsego Summit 1,200 "
The rivers have all eroded their valleys into the loose
drift masses which almost universally cover the surface of
the peninsula in great thickness. Only in rare instances
have they been deep enough to touch the solid rock ledges
below the drift, or, if sucb deep cuts did exist, they have
rilled them up with debris, and the beds of the present
streams lie high above those of former times. The penin-
sula was, in its original condition, heavily timbered, with
the exception of a few marshy flats. Climate and quality
of the soil determine the character of the vegetation. In
the southern part of the peninsula deciduous trees, particu-
larly hard-wood timber, prevail. Pine is only sporadically
intermingled. The mildness of the climate favors the
growth of the oak, hickory, walnut, poplar, etc., which
abound here, but become rarer farther north, where beech,
maple, and birch take their place. The sandy soil of the
central high plateau is most congenial for the growth of
pine forests, which have taken possession of nearly the en-
tire district. The marshy condition of some other places
adapts them for the tamarack, elm, asp, and willow trees, or
for the growth of the cedar, while a few parts of the high
plateau, proving too sterile even for the pine, afford suste-
nance to nothing more than a stunted scrubby growth of
Finns banksiana, and a few creeping herbs which attempt
to hide the barrenness of the scene. Such barrenness has,
in some instances, been caused by fires which annihilated
forests of large area, totally denuding the surface, and leav-
ing it exposed to the burning rays of the sun and to the
exsiccating winds, and unable for a long time, if not for
ever, to recover its former well-timbered condition.
" The entire surface of the peninsula is covered by heavy
drift deposits, with the exception of a few limited localities
in which the drift, subsequent to its deposit, has been washed
off by the floods, or by rivers curving their course deep
enough to touch the rock-beds of older formation. These
drift masses are almost the same as those of the upper pen-
insula. The material has been changed somewhat, by the
admixture of rock-debris, from the formations encountered
by the moving glaciers in their southern course. The gla-
cier-drift spreads itself in a compact body over the entire
surface of the lower peninsula, in evidence of which fact
the rock-beds, wherever they are found denuded and the
nature of the rock has been capable of preserving the
marks, bear the traces of its motion on their scratched sur-
face. Not all the drift material found on the lower penin-
sula has been transported there by glaciers ; a large por-
tion of it must have been carried southward by water,
partly in suspension — as mud and sand — partly frozen with
floating ice — as the coarser material, the gravel and the
bowlder.
" The glaciers deposited moraines — heaps of rubbish
composed of all kinds of rock-debris in every degree of com-
minution, from the large bowlder down to the impalpably
fine clay.
" Much of the drift is not found in this orderless form
of moraines, but is disposed in well-stratified layers, assorted,
according to the weight of its particles, by water-currents."
A long time of submergence of the land must have fol-
lowed the glaciers. The surface of the highest points of
the peninsula, 1,100 feet above the level of the lakes, is
formed by stratified drift-sand, mixed with pebbles.
" The older glacier-drift and the later deposit of floods
and icebergs are materially of the same composition ; both
are made up of clay, sand, gravel, and bowlders of detritus
from crystalline and metamorphic rocks, mixed with debris
of younger sedimentary strata."
The coarse bowlder-drift all through the southern part
of the peninsula appears not to occupy the lowest position,
in which most frequently a hard, dark blue, sandy clay,
with pebbles and some bowlders intermingled, is found in
layers of considerable thickness. It is known among la-
borers by the popular name of hard-pan.
" Bog-iron occurs very frequently in small patches of
marsh lands in all parts of the State."
" As another surface deposit, peat lias been mentioned.
Innumerable larger and smaller patches cover the swampy
surface depressions throughout the whole State."
SIIURLY: PHTHISIS PULMONALIS IN MICHIGAN.
[N. Y. Med. Jour.,
The soil of the lower peninsula, being a drift-soil, is gen-
erally very deep, and contains all the chemical constituents
of a good soil.
The assortment of the drift-soil into clay, sand, and
gravel determines its character as the layers happen to oc-
cupy the surface positions, while by intermixture a great
variety of intermediate shadings in the quality of the soils
is* locally produced under atmospheric influences. The dis-
tribution of soils over the State is sometimes very unequal
and changeable, so that within limited areas, and often
within single farms, a number of variations in the character
of the soil are represented. But with the differences seen
in the surface configuration of certain districts is also usual-
ly found a corresponding contrast in the quality of their
soil. The high plateau in the northern part of the penin-
sula has its peculiar soil, a thick, uniform mass of fine sand,
containing few pebbles and a small proportion of argilla-
ceous constituents. In accordance with it is its vegetation ;
the pine-tree finds a congenial home in these sandy hill-
lands, and their surface is overgrown with splendid forests
of this tree, to the exclusion of almost every other kind.
"Other districts — represented by lowlands adjoining the
lakes, and, to all appearances, within comparatively recent
times parts of the lakes' bottoms — are covered by a stiff clay
soil overgrown with elm, ash, and kindred trees, as, for
instance, the lower part of Saginaw Valley and a strip of
land bordering Detroit River, from Monroe up to Lake St.
Clair.
" The climate of the peninsula, which is the other prin-
cipal factor in its productiveness, is over the whole extent
temperate, extremes of heat or cold being prevented by
the surrounding lakes. From the northern to the southern
end all the cereals can be planted with little risk of failure.
The northern part is somewhat cold, its vegetation coming
out two weeks later than in the south, and the winter set-
ting in that much earlier, which affects somewhat the rais-
ing of the more tender fruit crops, as grapes, peaches, etc.
" The grape and the peach do well in the southern part
of the State, and particularly near the shores of the great
lakes, where the foggy, humid air prevents late frosts, the
greatest enemy of these fruits. The west shore up as far as
Muskegon has become famous for its peaches and other
small fruits."
" Beneath the drift the peninsula is underlaid by regu-
larly stratified rock-beds, in undisturbed horizontal position,
which represent the upper part of the palaeozoic strata."
In the following report it will be seen that under the
heading of County is given the name of each county ; under
the heading of Population is given the population by coun-
ties in 1870 and 1880, and under the heading of Number of
Deaths by Phthisis is given the total number of deaths from
phthisis from 1869 to 1882, inclusive. The column marked
Number of Cases originating in County gives the cases re-
ported to me from various physicians as having originated in
their county, with the year of their appearance. Of these,
the remaining columns, marked Primary and Secondary,
will show the number of cases as far as known which were
primary, and those which arose secondarily to some other
malady :
Deaths by Phthisis Pulmonalis in the State of Michigan.
Record by Counties.
COUNTY.
Population in
1870 and 1880.
No. of
deaths from
phthisis
from 18«9
to 1882.
Alcona
Allegan
Alpena
Antrim
Baraga
Barry
Bay
Benzie
Berrien
Branch
Calhoun
Cass
Charlevoix
Cheboygan
Chippewa
Clare
Clinton
Crawford
Delta
Eaton
Emmet
Genesee
Gladwin
Grand Traverse.
Gratiot
Hillsdale
Huron
Ingham
Ionia
Iosco
Isabella
Isle Royal
Jackson
Kalamazoo
Kalkaska
Kent
Keweenaw
Lake
Lapeer
Leelenau
Livingston
Lenawee
Michilimackinac.
Macomb
Manistee
Manitou
Marquette
Mason
Mecosta
Menominee
Midland
Missaukee
Monroe
Montcalm
Montmorency . . .
Muskegon
Newago
Oakland
Oceana
Ogemaw
Ontonagon
Osceola
Oscoda
Otsego
Ottawa
Presque Isle
Roscommon. . . .
Saginaw
Sanilac
Schoolcraft
Shiawassee
St. Clair
St. Joseph
Tuscola
Van Buren
Washtenaw
Wayne
Wexford
38,081
3,433
36,785
27,941
38,452
22,009
5,115
6,524
5,248
4,187
28,100
766 & 3,107
32,093 " 37,815
2,756 " 8,780
1,985 " 5,237
1,804
22,204 & 25,317
15,820
2,148
35,119
26,229
36,571
21,097
1,724
2,197
1,690
266
22,852
1,159
2,441 & 6,812
25,164 " 31,225
1,211 " 6,639
33,965 " 39,222
1,127
4,443 & 8,422
11,809 "
31,691 "
9,049 "
25,270 "
27,676 "
3,175 "
4,113 "
55
36,042 &
32,063 "
424 "
50,410 «
4,209 "
548 "
21,345 "
4,577 "
19,417 "
45,503 "
1,716 "
28,050 "
6,074 "
891 "
15,077 "
3,266 "
5,645 "
1,894 "
3,383 "
1,553
27,534 & 33,624
13,642' " 33,148
14,895
21,936
32,723
20,489
33,676
33,872
6,873
12,159
42,031
34,342
2,937
73,253
4,270
3,232
30,138'
6,253
22,251
48,343
2,992
31,627
12,532
1,334
25,394
10,065
13,973
11,987
6.893
292
26,586
14,688
40,906 " 41,537
7,222 " 11,699
1,914
2,846 & 2,565
2,104 " 10,777
467
1,974
26,665 & 33,126
3,113
355 & 1,459
39,078 " 59,095
14,565 " 26,341
1,575
20,864 &
36,687
26,274
13,721
28,735
41,412
119,054
650
27,159
46,197
26,626
25,738
30,807
41,848
166,444
6,815
155
506
58
37
17
332
415
45
602
467
653
308
63
30
63
22
348
2
43
450
84
515
3
65
180
577
135
424
469
56
172
550
618
12
1,114
27
22
314
81
324
693
44
544
109
11
258
87
122
25
80
5
470
295
251
107
618
160
6
34
62
1
2
455
14
915
250
9
307
572
430
247
478
683
4,237
45
No.
origina
ting in
county,
11
5
4
'81-'84
4
3
1,
82'-'84
15
13
2,
'80-'84
23
12
4,
'80-'85
9
'78-'84
3
2
'82-'84
15
28
98
35
8
30
10
21
1
13
4
30
36
49
10
2
15
62
14
15
29
9
13
396
Secondary.
3 2, '83-'84
6
'60-' 70
29
,!
6,
'70-'85
32
2
'81-'84
3
'80-'84
13
63
'70-'84
19
10
9,
"79-'85
2
1
'82-'84
100
16
1,
'57-'84
5
2
3,
'75-'84
13 17,'72-'84
10 '81-85
9 5, '82-'84
1 '80-'84
4 1, '80-'84
2 '64-'80
19 ll,'82-'84
14 |20,'71-'84
39 ]0,'74-'84
4 6, '80-'84
35 13,'74-'84
2 8, '80-'84
.. 2, '77-'84
14 |l, '72-'84
25 l30,'78-'84
9 2, '72-'84
5 jl0,'81-'84
18 ll,'06-'84
6 3, '79-'84
7 !6, '78-'84
237 85,'75-'84
Nov. 14, 1885.] KELSEY: INJECTIONS OF CARBOLIC ACID IN BMMORREOTDS.
5i5
It will be seen by these tables that the whole number of
deaths from phthisis pulmonalis, as reported to the State
Board of Health, from 1869 to 1882 (thirteen years) is
22,103, or an average of 1,700 a year. Of these, 1,241
were reported in 1869 and 1,979 in 1882.
During 1882 rain fell 179 out of the 365 days, with a
total fall of 30'31 inches, which was about the average fall
for the preceding ten years. The mean temperature for
1882 was 51 -2, which was slightly higher than the average
for the preceding ten years.
The whole number of cases reported to me as having
originated in the State between the years 1857 and 1885 is
1,370, and of these, 673, or nearly one half, were reported as
primary, while 205 were reported as having been secondary
to some other disease.
Of the total number of original cases (1,370) from 1857
to 1885, 602, or a little less than one half, occurred between
the years 1879 and 1885, or during a period of six years.
The total population of the State, according to the cen-
sus, in 1870 was 1,184,059, and in 1880 was 1,856,100,
showing an increase of 672,041 ; so that proximately, so far
as learned, the percentage of deaths from original cases to
population would be about T^g- per cent., which no doubt
is somewhat below the truth ; but, as before remarked, these
statistics are necessarily inaccurate (as are all United States
vital statistics). However, if enough has been elicited to
awaken an interest in the further investigation in this line,
the work may not prove entirely valueless.
Note. — A very full and able account of the climate and topography
of Michigan, illustrated by numerous maps, by Dr. H. F. Lyster, of
Detroit, may be found in the " Report of the Michigan State Board of
Health," for 1878.
HOW TO TREAT HEMORRHOIDS
BY INJECTIONS OF CARBOLIC ACID.
By CHARLES B. KELBEY, M. D.
The "many requests which I have received from members
of the profession for an exact description of this method
of treatment have decided me to write the following com-
munication, even at the risk of repeating what I supposed
I had already made sufficiently clear.
The injection of haemorrhoids with carbolic acid, though
apparently a simple and trivial affair, is to be regarded in
the light of a surgical operation, and should not be under"
taken by the practitioner until he has surrounded himself
and the patients with all the safeguards at his command.
There are two accidents which may happen in these
cases, and for which the operator must be on his guard-
One is undue ulceration, the other is abscess. Ulceration
is the result of using a strong solution, which causes a dis-
tinct slough of the tumor injected. The resulting ulcer is
seldom larger than a silver quarter, and I have never known
it to give rise to serious trouble or to refuse to heal kindly
with proper local treatment. When it occurs it is well to
cease further injections and to deal exclusively with tbia
condition until it is healed. Applications of nitrate of sil-
\ er, iodoform, calomel in powder, etc., arc usually sufficient
to induce cicatrization. The ulcer is not generally painful,
the discharge is about the only symptom of which the pa-
tient complains, and the complication is not therefore to be
considered as a serious one.
It will at once be asked what strength of solution is
capable of producing a slough ? I can not say. The worst
one I ever produced came from an injection of a fifteen-
per-cent. solution, and I have deliberately tried to produce
one in a large hemorrhoid by the use of undiluted carbolic
acid, and failed to get anything more than a hard tumor of
the size of the end of the thumb around the injection. The
individuality of the patient seems to exert a decided influ-
ence, and, given a certain standard strength of solution —
say thirty-three per cent. — it is impossible to predict be-
forehand in how many patients it will produce a slough
and in how many it will produce a simple induration. Of
course, as a general rule, it can be stated that weak solu-
tions are less apt to produce sloughs than the stronger ones,
but beyond this my experience does not yet enable me to
go, and I do not consider the question as one of very great
importance ; for these ulcers which result from a slough
heal fully as well as the wounds which follow either the
ligature or the clamp, and it is with these two methods of
operating that I wish the treatment by carbolic acid to be
compared. I hold it to be a surgical procedure, comparable
in its results with either of these, and to be judged on its
merits as compared with them. I believe that it possesses
many advantages over either of them.
The second complication is abscess, and these are of two
kinds — one trivial, the other serious. In two or three cases
I have seen the following chain of events : An injection of
medium strength being made, the patient has returned after
a few days complaining of a painful swelling. An examina-
tion has revealed a tumor of the size of the end of the thumb
situated just at the margin of the anus, covered with skin
on the outside and mucous membrane on the inside and
containing pus. If left to itself, such an abscess will often
discharge on both the mucous and cutaneous aspects, the
two openings being free and close to each other, and the
cavity will close spontaneously. An incision on the cuta-
neous surface, though it will relieve pain and evacuate pus,
may yet not prevent a spontaneous opening on the mucous
surface. When the two openings have formed, the result is
a subcutaneous fistula at the verge of the anus, but one
which in its results is a very trivial affair, and which, if it
does not heal spontaneously, can easily be laid open in the
surgeon's office, and dressed with lint from the bottom.
The other abscess is a much more serious matter, and I
have no doubt that it can be produced, and in some cases
has been, by an improper use of the acid. I refer to a deep
abscess of the cellular tissue in the ischio-rectal fossa.
Such cases have been described and are quoted as the chief
objection to this method of treatment. They are due to
the injection of too strong a solution, or of the undiluted
acid, either into a small tumor or into the cellular tissue en-
tirely beneath the tumor. The pure acid may be inserted
into a large hemorrhoid and cause a limited slough which
will result in a perfect cure. The same injection given
below a small tumor is pretty likely to cause a considerable
cellulitis. It is in this way that I explain this unfortunate
accident, which is rare at the most, is a result of the im-
546
KELSEY: INJECTIONS OF CARBOLIC ACID IN HEMORRHOIDS. [N. Y. Med. Jo. k.,
proper employment of the means at the operator's com-
mand, and ought not to be considered a valid objection to
the plan of treatment.
I have said that the injection of haemorrhoids reached
the dignity of a surgical operation, and should be judged in
comparison with other operations for accomplishing the
same end. This will almost certainly be found to be the
case in any extended experience. The suffering is not al-
ways trifling ; the nervous strain of submitting to any plan
of treatment is not inconsiderable ; the affection itself is
sometimes a serious one, and, as I have already said, the
operator should surround himself with all the safeguards
within his reach. During the past summer I was called
upon to treat an old gentleman, the mayor of a small town
in Ohio, living in a high, cool, country region, but much
depressed with business losses and worry. He came to
New York in the middle of the hot season and submitted
to treatment. The haemorrhoids were the worst which up
to that time I had ever treated by this method. The
sphincter was much relaxed; the tumors had been down for
twenty-rive years without being replaced, and were very
large and vascular. There were three distinct masses, each
of about the size of a hen's egg. The case was not an at-
tractive one, considering the age and condition of the pa-
tient and the hot weather, but I undertook it. Into the
largest of the three tumors I injected five drops of a fifty-
per-cent. solution. It was followed by a good deal of pain
and loss of sleep for two nights, with some constitutional
disturbance. On the third day, the pain of the first injec-
tion having somewhat subsided, I injected five drops of
pure acid into the second tumor, and had much less trouble
than with the fifty-per-cent. solution in the former case.
After three days more I again injected the same amount of
pure acid into the third tumor. Both of these last applica-
tions caused a distinct slough with resulting ulcerated sur-
face and free discharge of bloody matter. After a few days
more I returned to the first tumor, which had not sloughed
but simply become indurated, and injected five drops of
pure acid into that. The applications were all made within
the space of two weeks. During this period the patient
allowed his bowels to become constipated, and I had to
clean them out with repeated copious enemata. There
was at one time some vesical irritation and decrease in.
the amount of urine, whether from direct absorption of
carbolic acid or from reflex irritation I do not know, and
at the end of the treatment the patient was considerably
reduced in strength — so much so that I put him upon the
most nourishing regimen with bark and whisky. Just as
he seemed on the point of rallying I discovered a small ab-
scess in the perinaeum, which was opened, and healed kindly,
having no connection with the rectum. After recovering
from this and gaining a considerable degree of health he
went to his home in Ohio, and was immediately brought to
bed with a second, larger abscess on the buttock. From
this he also made a good recovery, and has ever since been
perfectly well, the haemorrhoids causing no disturbance
whatever.
This was a bad case, and for that reason I am willing to
consider it as a teat one. The haemorrhoids were the largest
I have ever seen operated upon by this or any other opera-
tion. The patient was seventy years old, and, though free
from organic disease, was not in good general condition.
The piles were cured by four injections of carbolic acid. It
is true he suffered pain, he had some vesical irritation, and
he had two abscesses due to his general enfeebled condition,
but having no connection with the rectum. Taking the
case as it stands, the operation will compare very favorably
with either Allingham's or Smith's. The man was not con-
fined to his bed at any time, and, moreover, would not sub-
mit to either of the other operations under any circum-
stances. Being one of the worst cases I have ever had with
carbolic acid, I am still willing to place it in comparison
with the average case of operation by the ligature, looking
at both in the light of surgical procedures of considerable
magnitude and importance.
The objections to and possible complications of this
method of treatment are, therefore, easily enumerated.
They are, 1, pain; 2, vesical irritation where strong solu-
tions are used; 3, marginal abscess; 4, deep cellulitis.
In the majority of cases the patient will escape them all.
Deep cellulitis I should suppose to be about as frequent
after this operation as pyaemia after the ligature. Marginal
abscesses may occur at any time, but are easily treated.
The vesical symptoms never follow any but the more pow-
erful injections, and the pain is very variable and can not
be predicted from the strength of the solution used. I
have injected five minims of pure acid into a large tumor
without the patient either knowing: when it was done or.
appreciating the slightest sensation afterward. I have in-
jected a fifteen-per-cent. solution into a small tumor and
caused considerable suffering. Speaking in a general way,
I do not expect much pain from a weak solution, but, never-
theless, it is sometimes met with, and I have ceased to
predict its presence or absence. If it comes with any solu-
tion I am not surprised, and if it does not come I am
pleased. It is, however, an exception to meet with it to
any marked degree.
As far as I have been able to reduce this treatment to a
matter of rule the results are as follows :
1. Use only the purest crystallized carbolic acid, the
purest glvcerin, and distilled water in the preparation of
the solutions. Each, when prepared, should be perfectly
colorless and clear, the acid being in perfect solution. The
glycerin is added to the solution of carbolic acid in water
in just sufficient quantity to make a clear fluid, and the
amount is not important. As soon as a solution begins to
assume a yellowish tint it should be replaced by a fresh one.
2. Use onlv the finest and most perfect hypodermic
needles and a perfectly working, clean syringe with side-
handles. After each injection when the syringe is put away,
clean it thoroughly, to be ready for the next time.
3. The treatment may be applied to every variety of
internal haemorrhoids, no matter what their size. It is not
applicable to external haemorrhoids, either of the cutaneous
or the vascular variety, both of which may be treated by
better means.
4. Before making an application give an enema of hot
water, and let the patient strain the tumors as much into
Nov. 14, 1885.]
CLINICAL REPORTS.
547
view as possible. Then select the largest and deposit five
drops of the solution as near the center of the tumor as pos-
sible, taking care not to go too deep so as to perforate the
wall of the rectum and inject the surrounding cellular tis-
sue. The needle should be entered at the most prominent
point of the tumor. If the hajmorrhoid does not protrude
from the anus, a tenaculum may be used to draw it into
view. After the injection has been made the parts should
be replaced, and the patient kept under observation for a
few minutes to see that there is no unusual pain. The in-
jection will cause some immediate smarting if it is made
near the verge of the anus ; if made above the external
sphincter, the patient may not feel the puncture or the in-
jection for several minutes, when a sense of pressure and
smarting will be appreciated. In some cases no pain will
be felt for half an hour, but then there will be considerable
soreness, subsiding after a few hours. If it increases, in-
stead of disappearing, and on the following day there is
considerable suffering, which may not perhaps be sufficient
to keep the patient on his back, but is still enough to make
him decidedly uncomfortable, it is a pretty good indication
that a slough is about to form. For the reason that it is
impossible to tell absolutely what the effect of an injection
is to be until at least twenty-four hours have passed, it is
better to make but one at a visit and to wait till the full
effect of each one is seen before making another. If on the
second day there is no pain or soreness, another tumor may
be attacked, and this will often be the case.
5. The strength of the solution must be regulated by
the nature of the case, and in my own practice varies from
five per cent, to pure crystallized acid. In a large, vascu-
lar, prolapsing tumor, which is well defined and somewhat
pedunculated, five drops of pure acid may be used with the
expectation of producing a circumscribed slough which will
result in a radical cure. A thirty-three-per-cent. solution
under the same conditions will probably produce consolida-
tion and shrinkage without a slough, but the injections
will have to be repeated several times. A small tumor
which protrudes but slightly, is not pedunculated, and can
be seen and felt as a mere prominence on the mucous mem-
brane, may be cured by a single injection of a five-per-cent.
solution, which will cause it to become hard and decidedly
reduce its size, while an injection of a fifty-per-cent. solu-
tion might make considerable trouble, the remedy being too
powerful for the disease. Guided by this principle, some
experience will soon determine the choice of the solution.
There is no arbitrary rule which can be applied to every
case. As in any other surgical operation, some cases will
be more satisfactory than others, and an occasional accident
must be expected ; but, on the whole, it seems to be the
best method of treatment yet devised.
25 Madison Avenue.
The New York Academy of Medicine. — The Section in Practice of
Medicine will hold a meeting on Tuesday evening of next week, in the
Academy's parlors. Dr. R. C. M. Page will read a paper on " Blight's
Disease," and the discussion of the subject will be participated in by
Dr. E. G. Janeway and Dr. Francis Delatield. A discussion on the
question "Is Croupous Pneumonia an Inflammation or a Fever?" will
be opened by Dr. William H. Draper.
Clhiiml Sports.
ROOSEVELT HOSPITAL.
Clinical Remaeks by Dr. Henet B. Sands.
Abscess of the Knee. — Osteitis of the Tibia. — Excision of the Knee
Joint.
We have before us, gentlemen, two cases of strumous dis-
ease of the knee :
Case I. — The first patient is a man, twenty-three years old,
who has had disease of the left knee joint for four years. I
will postpone giving you a complete history of his case until
some future occasion, when he will probably undergo the
operation of excision of the joint. To-day I intend simply to
evacuate a large abscess which has formed since the patient en-
tered the hospital five weeks ago. At that time the character
of the disease was evident. The knee joint was semiflexed,
painful, and swollen, its circumference being two inches and a
half greater than that of the sound one. The swelling was
fusiform, and did not fluctuate. The patella was in contact
with the femur, and was not adherent. Pain was felt on press-
ing together the articular surfaces, and also on making flexion
or rotation, which was accompanied with the crepitus charac-
teristic of erosion of the articular cartilages. Further evidence
of disorgnnization was found in the existence of a fistulous
opening on the outer side of the knee, and in a partial luxation
backward of the tibia.
I considered the case a proper one for excision ; but, in con-
sequence of the recent development of an abscess of consid-
erable size on the inner aspect of the joint, I have decided to
defer this operation until the abscess has been opened and its
walls have been allowed to contract. It is doubtful whether
the abscess communicates with the cavity of the joint, because
the latter is not at all distended, and because firm pressure upon
the abscess fails to displace its fluid contents. In any case,
however, incision is the proper remedy.
Having now opened the abscess, and permitted the discharge
of several ounces of well-formed pus, I am unable to discover
any communication with the joint cavity. A probe introduced
through the sinus on the outer side of the knee also fails to en-
ter the joint. I will conclude the operation by irrigating the
abscess with a solution of mercuric bichloride, 1 to 1,000, in-
serting a drainage-tube dusted with iodoform, and applying a
wood-wool dressing.
Case II. — C. R., twenty-four years of age, was sent into the
wards from the Out-door Department, March 2d. Family his-
tory good. The patient is a healthy-looking woman, who de-
nies syphilis. She states that eleven years ago there occurred
spontaneously a painful swelling of the right tibia near its mid-
dle and upon its inner surface. This swelling has never disap-
peared, and has usually been painful. She has taken iodide of
potassium at various times, and is now recovering from the
effects of mercurial treatment, which has failed to afford relief.
On examination, there is found a painful, hard swelling over
the right tibia at the junction of its lower and middle thirds on
its inner surface. The swelling is apparently connected with
the bone and periosteum. It is quite firm, and shows no point
of fluctuation.
The prominent features of the case are the long duration of
the disease and the mildness of the symptoms, which are those
of chronic osteitis or periostitis. Occasionally, as has happened
in the present instance, internal remedies prove to be useless,
and in these circumstances relief may often be afforded by freely
incising the periosteum. I shall resort to this expedient now,
548
BOOK NOTICES.
[N. Y. Mkd. Joctr.*
and shall, perhaps, also trephine the thickened bone, so that I
may be able to explore the medullary canal and liberate any
inflammatory products that may be found there.
Having divided the soft parts down to the bone, and removed
a disc of the latter by means of a trephine, I can discover
nothing besides an inflammatory thickening and condensation
of the affected parts, no signs existing of caries, necrosis, or ab-
scess. An iodoform dressing will be applied, and the wound
allowed to heal by granulation. Some benefit to the patient
may be anticipated from the operation.*
Case III. — This is one that requires excision of the knee.
The patient is a German, twenty-nine years old, whose mother
died of pulmonary consumption, and who, fourteen years ago,
had symptoms of phthisis, which, however, were of short dura-
tion. In 1875 the distal phalanx of his right index-finger was
amputated for what seems to have been a tuberculous affection
of the neighboring joint, accompanied with cheesy abscesses
near the elbow and in the axilla, which remained open for eight
months. About the same time a cold abscess formed below his
right knee. This was incised, and healed three months after-
ward. Two years ago the knee joint began to swell and became
somewhat painful. Gradually the disease grew worse, and the
patient found it difficult to walk, chiefly on account of flexion
of the knee, for which, he says, he was treated last winter by
tenotomy of the hamstrings. When he entered the hospital,
December 10, 1883, his right knee was swollen, partly in conse-
quence of a moderate effusion of fluid in the joint cavity, and
also on account of a thickening of the capsule and other deep
soft tissues. The circumference of the knee over the patella
was sixteen inches, that of the sound knee being fourteen. The
patella was movable. Flexion could be made to nearly a right
angle, and extension to nearly a right line, without causing pain
or crepitus. Deep fluctuation could be felt across the joint
above the patella. In addition to the joint-disease, a large cold
abscess occupied the upper third of the leg on its inner and pos-
terior aspects, fluctuation being distinguishable as high as the
flexure of the knee. This was freely opened, on December
15th, by my house surgeon, who made two incisions at oppo-
site points, evacuated the abscess as thoroughly as possible,
washed it out with a solution of mercuric bichloride, inserted
rubber drains, and applied a peat dressing. On January 15,
1884, three weeks ago, I opened and drained the knee joint,
making an incision about one inch in length on each side above
the patella. During this operation I discovered that the articu-
lar cartilages were extensively destroyed, leaving the bone ex-
posed, and I should have performed excision at once had I ob-
tained the man's consent. At present, however, his condition
is very favorable for the operation, and it is doubtful whether
anything has been lost by the delay. The knee may be said to
be neither better nor worse; it is slightly reduced in size, yet
we shall find abundant evidence of disorganization when the
joint is exposed to view. But, meanwhile, the large cold abscess
referred to has undergone a remarkable change, having shrunk
to the dimensions of a narrow sinus, which will not interfere
with the success of excision.
Regarding the propriety of undertaking an operation I think
there can be no doubt. The diagnosis of tubercular or strumous
arthritis is made sufficiently evident by the clinical history, and
has been corroborated by the discovery of tubercle bacilli in the
fluid obtained from the joint, which was examined microscopic-
ally by Dr. Hall. The duration of the disease and the exist-
ence of suppuration render recovery, even by ankylosis, ex-
* Pain diminished immediately after the operation, and disappeared
entirely on the fifth day. It had not returned when the patient left the
hospital, on the seventeenth day, the wound at that time being nearly
healed.
tremely improbable, and the only point to be decided is whether
to perform excision or amputation. The patient's own prefer-
ence for the former operation, the fact that he is an adult, his
good general health, the absence of extensive sinuses communi-
cating with the joint, the slow progress of the disease, the proba-
bility that the bony tissue has not been extensively destroyed,
the increased chances of success afforded nowadays by antisep-
tic methods of operation — these are mainly the circumstances
which induce me to make an attempt to save the limb by re-
sorting to excision.
Having now completed the operation, I will briefly remind
you of its principal points of interest. A broad antero-lateral
flap, the lower margin of which corresponded with the level of
the tubercle of the tibia, was reflected upward, and the joint
exposed by cutting through the ligamentum patellae. Many
other forms of incision have been adopted, but this one I prefer
as being convenient and as affording ample space for the removal
of the diseased parts. After dividing the lateral, capsular, and
crucial ligaments, the interior of the joint was thoroughly ex-
posed to view, and it was then discovered that, as we had anti-
cipated, the degenerative changes were most striking in the soft
parts, the synovial membrane being everywhere greatly thick-
ened and covered with exuberant, pulpy granulation tissue.
Partly by the use of a sharp spoon, but chiefly with the aid of
scissors, the diseased synovial membrane was completely re-
moved. This step of the operation is tedious, but important,
as there is reason to believe that failure often results from
neglecting to perform it thoroughly. The synovial pouch, or
cul-de-sac, which lies behind the quadriceps extensor, is some-
what difficult of access, as well as the synovial membrane at
the back part of the joint, which can be efficiently dealt with
only after removal of the articular extremities of the femur and
tibia. The cartilages were extensively diseased, and at some
points had disappeared, leaving the bone bare and soft. A thin
slice of bone was sawed from the tibia and an inch removed from
the femur. The patella was extirpated, and a small carious
cavity in the head of the tibia scraped out with a gouge. The
sinus in the leg was also explored and well scraped with a sharp
spoon. It did not seem to communicate with the joint. To
secure accurate contact of the sawed bony surfaces, three steel
nails were driven into the femur and tibia, two from above
downward through the condyles into the head of the tibia, and
one from below upward in the median line. These nails per-
forated the skin, beyond which they were allowed to project
about an inch. Bone-drains were inserted into the wound at
four different points, and a rubber drain was introduced into
the sinus of the leg. The wound was closed with a continuous
catgut suture, and covered with bichloride gauze and a bag of
wood-wool. Finally, the limb was firmly secured in a long
posterior metal splint provided with a foot-piece. Such a splint
gives adequate support to the limb, and is preferable, in my
judgment, to the more complicated kinds of apparatus which
have been invented for the same purpose. One object of the
operation being to cause a fusion of the sawed bony surfaces,
motion of the limb will be carefully avoided, and the dressings
changed as seldom as possible.
ook flotttes.
BOOKS AND PAMPHLETS RECEIVED.
The Medical Student's Essentials of Physics. By Condict
W. Cutler, M. D., late House Physician, Bellevue Hospital, etc.
New York : J. H. Vail & Co., 1884. Pp. 192.
Nov. 14, 1885.].
L EA DING ARTICL ES.
549
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Applbton & Co. Frank P. Fobtek, M. D
NEW YORK, SATURDAY, NOVEMBER 14, 1885.
THE BOARD OF HEALTH'S ESTIMATE.
Me. James Gallatin has written a letter to the Board of
Estimate and Apportionment, in which he protests against cer-
tain items in the Health Department's estimate of the funds it
will require for the year 1886. In the first place, as to the al-
lowance of $12,200 for the attorney's and counsel's office, he
thinks that a young attorney, at $1,200 a year, would be fully
competent to write " lawyer's letters " for the board, and that
any other further legal assistance required in carrying out the
present policy of the board could be readily obtained by an oc-
casional detail from the Corporation Counsel's office. As to the
allowance of $24,000 for twenty additional sanitary inspectors,
Mr. Gallatin says that, if these additional inspectors are needed,
it is only because the time and the energies of the present in-
spectors are wasted in repeated inspections of nuisances, the
board having failed to secure the prompt abatement of these
nuisances by inflicting the penalties prescribed by the law. The
expenditure of the $2,000 allowed for marshal's fees is, he thinks,
in great part a scandalous waste of the city's funds; and, to sub-
stantiate this criticism, he remarks that, instead of compelling un-
successful defendants in civil suits to pay the fees, the board
very obligingly pays the fees for them. Finally, he protests in
general terms against any increase of the appropriation for the
department, on the grounds of wastefulness in its expenditures
and inefficiency in its management ; and he expresses the opin-
ion that a considerable reduction of the appropriation would not
be accompanied with any injury to the public interests.
This is a scathing arraignment of the Board of Health, but
it must be confessed that, in the pamphlet issued by Mr. Galla-
tin, he accompanies his letter with sundry citations, including
that of the recent action taken by the Grand Jury, that go far
to show that a strict and prompt enforcement of the penalties
which the board is empowered by 1 aw to impose would resul
in a great saving of funds, and do away with the assumed need
of additional sanitary inspectors. On the other hand, it should
not be forgotten that much is left to the board's discretion in
this matter, and that, inasmuch as sanitary requirements are
almost always fraught with hardship, and are very generally re-
garded as odious, the board's leniency should not be too harshly
criticised so long as it can be shown to be impartial. The truth
seems to be that penalties should he prescribed for infractions
of a sanitary code to be made by the Legislature itself, and not
by the Board of Health, and that the enforcement of these pen.
alties should then be made mandatory upon the board— the code,
of course, to include only the minimum of requirements. We
should then be in favor of the most ample appropriation, the
remuneration of the present inspectors to be increased, how-
ever, rather than their number to be added to. As regards the
legal expenses estimated by the board, they do seem unneces-
sarily large.
LIFE INSURANCE AND THE FAMILY PHYSICIAN.
The question of the value of the family physician's certifi-
cate as to the condition and health-history of any given indi-
vidual whose life is proposed to be insured is one that has
often been discussed more or less fully, and one that is doubt-
less correctly appreciated in the main by the life insurance com-
panies. It has lately been made the subject of public con-
sideration in some of the German journals, particularly the
" Deutsche Medizinal-Zeitung " and the " Allgemeine Versich-
erungs-Presse." From what we have seen in those journals,
we fail to perceive that any particularly new light has been
shed upon the matter, but it is one that will bear consideration
from time to time.
From the family physician's standpoint, it is no doubt a
nuisance to be required to furnish a sworn statement in which
for a trifling fee, if indeed for any at all, he is expected by the
"risk" (who in many cases has never really been his patient)
to furnish a clean bill of health, without any ifs or ands, and
by the company to communicate without reserve anything
that he may know, or infer, or surmise, bearing in the con-
trary direction. On the other hand, the company's medical
officer naturally gets to have an overweening confidence in his
own powers of physical exploration, and in his capabilities for
making a retrospective diagnosis ; and is, hence, apt to chafe
under the implied obligation to take a tertium quid into con-
sideration. In view of these two embarrassing circumstances,
it may well be doubted if the family physician's certificate often
throws much light on the real state of the case. Nevertheless,
life insurance is in some sense the right of anybody who can
pay for it, and who can not be shown beyond reasonable doubt
to be a proper subject for it. It is undeniable that in certain
cases the family physician can conscientiously add information
which will put a new color to the facts and statements elicited
in the company's examination — sometimes to the applicant's just
advantage, and sometimes in furtherance of the company's safety.
Hence, the family physician's certificate can scarcely be denied
to be occasionally an important factor in leading to an equita-
ble decision.
APOTHECARIES' WEIGHT AND MEASURE.
On more than one occasion we have pointed out the short-
comings of the metric system as applied to prescription-writing.
Its peculiarities satisfy little else than a sentiment, while one of
them — the decimal point — is so much of a stumbling-block in
actual practice that probably in not a few instances mistakes
involving loss of life have been due to it. Only last week we
alluded to a dispenser's error that was attributed by him in
part to the confusion into which ho was thrown by a prescrip-
tion written according to the metric system. We have nothing
to say against the use of the system in strictly laboratory work,
even of a pharmaceutical nature, but we can not conjure up a
550
MINOR PARAGRAPHS.
fN. Y. Mki>. -lorn.,
valid argument against dropping it once for nil in the matter of
prescriptions. It is, therefore, with the greatest satisfaction
that we have read an article in the current number of the
"Pharmacist," contributed by Mr. Oscar Oldberg, whose name
deservedly carries with it great weight in regard to such ques-
tions. As Mr. Oldberg states, he has for several years been an
earnest advocate of the adoption of the metric system in this
country for medical and pharmaceutical purposes, and it is very
much to his credit that he now frankly abandons his former
position, especially as he gives the most cogent reasons for so
doing.
While he rejects the metric system, Mr. Oldberg thinks it
desirable to connect our system with it, and he shows how this
could be done by modifications of our apothecaries' weight and
measure that would be so trifling as scarcely to affect their
present value in prescription- writing. There is no reason, he
says, why we should not modify a system that has come down
to us from colonial times, especially as it is no longer adhered
to in Great Britain. The minim has shown itself to be a most
useful unit of measure, its great practical advantage being its
approximation to the drop of most liquids at ordinary tempera-
tures. For convenience in dividing the fluidrachm, he proposes
that it should consist of sixty-four minims instead of sixty, in
which case we should be able to write one half, one quarter,
one eighth, one sixteenth, and one thirty-second of a fluidrachm,
each of which quantities would represent a certain Dumber of
whole minims. The new fluidounce, which would contain eight
of these fluidrachms, might be made equal to thirty-two cubic
centimetres, and therein would be found a convenient point of
connection between the proposed system and the tnetric system.
As the present fluidounce is equal to 29-573 cubic centimetres,
it will be seen that the change required would be practically
unimportant as concerns doses, the strength of solutions, and
the like. For the details proposed by Mr. Oldberg we would
refer our readers to his article in the " Pharmacist," a careful
reading of which we would commend to them.
MINOR PARAGRAPHS.
THE MEDICAL SOCIETY OF THE STATE OF NEW YORK.
TnE volume of " Transactions " for the current year has
reached us, and we find that it includes many papers and dis-
cussions of more than transitory interest. The volume bears a
Syracuse imprint, and the typography seems to us an improve-
ment on that of most of the volumes of the series. The appen-
dix, although brief, is particularly valuable, since it gives, either
in full or in abstract, such of the Acts of the Legislature of 1885
as are of interest to the medical profession. The lists of the
members of the society, and of the medical societies of the
counties, are published in a separate volume. The secretary,
Dr. William Manlius Smith, of Syracuse, is to be congratulated
upon the creditable appearance of the volume.
It appears that the delegations from eighteen constituencies
will become vacant February 1, 188G, and should be filled in
time for the delegates to attend the next annual meeting. These
constituencies are the medical societies of the counties of Che-
nango, Clinton, Columbia, Cortlandt, Erie, Hamilton, Herkimer,
Kings, Madison, St. Lawrence, Suffolk, Ulster, Washington,
Wayne, and Westchester, the medical department of the Uni-
versity of the City of New York, the New York Academy of
Medicine, and Bellevue Hospital Medical College.
THE SMALL-POX IN MONTREAL.
Neither the small-pox itself nor the unpleasant incidents of
its outbreak can be said to have shown any amelioration in
Montreal. The Mayor of the city, having been iutemperately
accused in one of the newspapers of barbarous and inhuman
conduct in enforcing the ordinance under which a certain child
was forcibly taken from its home, in spite of its father's resist-
ance, and carried to the hospital, that officer has brought suit
for libel against the newspaper. While it may conscientiously
be questioned how far, in the absence of a criminal charge, the
sanitary interests of a community justify a forcible violation of
the sanctity of the household, it is certainly unfair to hold an
official up to abuse, and virtually egg on popular vengeance
upon him, for simply executing the law. The sympathy of
every right-minded person, therefore, whatever he may think
of the abstract right of the matter, will certainly be with Mayor
Beaugrand in this affair.
"THE DOCTOR'S LOST WATCH."
Under this heading one of the New York newspapers — one,
too, that is generally careful not to offend against decency — pub-
lishes what purports to be a detective's story of bis having
tracked a thief who stole a watch from a well-known New York
surgeon. Although no names are mentioned, hundreds of New
Yorkers must have had no difficulty in recognizing the person-
ality of the doctor, who, we may well believe, must resent this
sort of notoriety. But, worse than that, the story plainly indi-
cates to almost as many people who the culprit was, and thus,
without the formality of a judicial investigation, consigns him
to disgrace, and wantonly exposes the family affairs of his father,
a most worthy citizen.
PUBLIC VACCINATION IN NEW HAVEN.
The Selectmen of New Haven, having taken in charge the
business of providing for public vaccination, are reported to
have determined upon doing so on what they term " business
principles," i. e., buying the cheapest vaccine and hiring the
cheapest doctors to use it. The physicians of the city very
properly resent this sort of action, and certainly nothing but
downright luck can prevent its proving disastrous. It is well
to remember that anything that is worth doing at all is worth
doing well.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending November 10, 1885 :
DISEASES.
Week ending Nov. 3.
Week ending Nov. 1C
Cases.
Deaths.
Cases.
Deaths.
39
9
23
6
34
5
20
5
Cerebro-spinal meningitis. . . .
4
5
1
1
5
1
5
1
51
' 18
56
25
2
0
8
2
The Health of Foreign Cities.— We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office since
the date of the last bulletin, November 4th: Montreal, Canada.
Nov. 14, 1885.1
MINOR PARAGRAPHS.
551
For the week ending November 4th : 233 deaths from small-
pox in the city, and 89 in adjoining municipalities. Kingston,
Canada, October 30th : Free from epidemic diseases. Toronto,
Canada. — For the week ending October 28th: 1 death from
small-pox ; the first that has occurred in the city. Havana,
Cuba— For the week ending October 31st: 25 cases and 12
deaths from yellow fever. Matanzas, Cuia, October 28th : Free
from epidemic diseases. Acapulco, Mexico. — For the week end-
ing October 18th : No deaths from contagious diseases reported.
Callao, Peru. — For the week ending September 19th: 1 case
and 1 death from yellow fever and 1 death from small-pox.
London, England. — For the week ending October 1 7th : No
deaths from small-pox, it being the first week since November,
1883, in which no deaths from the disease were reported. At
the end of the week 111 cases remained in hospital. Glasgow,
Scotland. — For the week ending October 17th: 1 death from
small-pox. Edinburgh, Scotland. — For the week ending Octo-
ber 3d : 1 case of small-pox reported. Paris, France. — For the
week ending October 17th : 5 deaths from small-pox ; 40 cases
under treatment in hospital. Bordeaux, France. — For the week
ending October 17th: No deaths reported from contagious dis-
eases. Antwerp, Belgium. — For the week ending October 17th :
3 cases and 3 deaths from small-pox. Cadiz, Spain, October
17th: No cases of cholera reported since October 14th. During
the week new cases were reported at St* Mary's and Seville.
Barcelona, Spain. — For the week ending October 10th : 340
cases and 126 deaths from cholera. The disease is abating and
becoming milder in form. Tarragona and Valencia reported
free from cholera since October 1st, and it is expected that these
ports will be declared clean at an early date. Genoa, Italy. —
For the week ending October 18th : 1 case and 1 death from
small-pox. Venice, Italy. — From October 13th to 17th: 16
i deaths from small-pox. Prague, Bohemia. — For the week end-
ing October 22d : 1 death from small-pox. Trieste, Austria. —
For the week ending October 10th : 8 cases and 2 deaths from
small-pox. Riga, Russia. — For the month of August: 1 death
from small-pox. Bombay, India. — From July 28th to August
18th: 35 deaths from cholera. Shanghai, China. — From Sep-,
tember 4th to 18th: 7 cases and 4 deaths from cholera among
the floating population. It is reported that hundreds of deaths
are occurring weekly among the Chinese. Colombo, Ceylon. —
2 cases of cholera reported since September 12th. In Italy, from
September 27th to October 6th, there were 1,643 cases and 754
deaths from cholera. Of these, 1,270 cases and 58 deaths oc-
curred in the city of Palermo. In Spain, from March 4th to
October 8th, there were 271,223 cases and 100,370 deaths from
cholera.
The New York County Medical Association.— At the
next meeting, to be held at the Murray Hill Hotel on Monday
evening, the 16th inst., Dr. Austin Flint will read a paper on
" The Elements of Prognosis in Bright's Disease," Dr. J. W. S.
Gouley will show photographs of pathological specimens taken
while the specimens were immersed in water, and Dr. E. G.
Janeway will present pathological specimens.
Medical Association of Central New York.— The eigh-
teenth semi-annual meeting will be held in Syracuse on Tues-
day, November 24th. The following papers are expected to be
read :
" Remedial Gymnastics," by Dr. L. A. Weigel, of Rochester;
"The Rhythm of Fever," by Dr. P. D. Carpenter, of Pittsford ;
" Packing in Uterine Displacements," by Dr. Streeter, of Roches-
ter; "Pneumonia," by Dr. J. II. Jewett, of Canandaigua;
" The Principle of Classification of the Chronic Insane," by Dr.
E. II. Howard, Superintendent of the Monroe County Insane
Asylum ; " Alteration of Nutrition Due to Disease of the Spinal
Cord," by Dr. Edward B. Angel, of Rochester; " An Improved
Self-retaining Sims's Speculum," by Dr. C. E. Darrow, of
Rochester; "Report of Several Typical Cases of Pernicious
Anfemia," by Dr. J. E. Smith, of Clyde; "Pessaries, their Uses
and their Abuses," by Dr. A. Dann, of Rochester ; Graves's
Disease," by Dr. William C. Bailey, of Albion.
By a standing resolution, all members of the county societies
in the jurisdiction of the association are invited to be present
and participate in the work.
The Society of Medical Jurisprudence and State Medi-
cine held a meeting on Thursday evening. The order of busi-
ness included a paper on " Compulsory Vaccination," by Dr. J.
Henry Fruit night.
The late Dr. Armor.— On Friday evening of last week a
meeting was held at the Long Island College Hospital, in memo-
ry of the late Dr. Samuel G. Armor. Addresses were made by
Dr. A. J. C. Skene, Dr. Jarvis S. Wight, and Dr. Francis H.
Stuart, and a memorial hymn was sung by a quartet of students
of the college.
The Manhattan Hospital.— A fair in aid of this institution
was opened at the University Club Theatre on Monday evening.
From the large attendance it is fair to infer that this deserving
institution has profited handsomely by the undertaking.
The Brooklyn Training School for Nurses— On Mon-
day evening a class of ten young women took their diplomas.
Remarks were made by Mayor Low, the Rev. Dr. McLeod, and
Dr. J. C. Hutchison.
Bequests to Charitable Institutions.— The following are
mentioned as among the legatees under the will of the late Mr.
John P. Howard, of Burlington, Vt. : the Association for the
Relief of Respectable Aged Indigent Females, in New York ;
the Home for Destitute Children, in Burlington ; the New York
Society for the Relief of the Ruptured and Crippled ; St. Luke's
Hospital, New York ; the New York Juvenile Asylum ; the
New York Children's Aid Society; and the New York Orphan
Asylum. It is said that about two hundred and fifty thousand
dollars are to be divided between these institutions.
The Hempstead Church Restoration Fund.— We have to
acknowledge a contribution of $20.00 from Dr. W. T. Lusk, and
one of $1.00 from Dr. J. Leonard Corning.
The Death of Professor William B. Carpenter, of Lon-
don, is announced as having taken place on Tuesday, as the
result of burns caused by the upsetting of a lamp while he was
taking a vapor bath for rheumatism. Dr. Carpenter was in the
seventy-third year of his age. As a physiologist he was proba-
bly better known to English-speaking people than any of his
contemporaries, as his writings, which were models of clearness,
were largely read by the laity. Three years, ago he delivered
the Lowell Institute lectures on "Human Automatism," in Bos-
ton, all but one of which were published in full in this journal.
By his death, although in the fullness of years, biology loses
one of its brightest ornaments, and society a noble man.
Naval Intelligence.— Official List of Changes in the Medi-
cal Corps of the United States Navy for the week ending Novem-
ber 7, 1885.
Kindlebekgkr, David, Medical Director. Granted leave of ab-
sence to June 30, 1886, with permission to leave the United
States.
Wikhek, F. W. F., Assistant Surgeon. To remain on Receiving
Ship Vermont until May 15, 1886.
552
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jole.,
Society Meetings for the Coming Week :
Monday, November 16th : New York County Medical Associa-
tion ; Medico-Chirurgical Society of German Physicians :
Hartford, Conn., City Medical Association; Chicago Medical
Society.
Tuesday, November 17th : New York Academy of Medicine
(Section in Theory and Practice of Medicine); New York
Obstetrical Society (private) ; Medical Society of the County
of Kings; Ogdensbur<r, N. Y., Medical Association; New
York State Medical Association (first day — New York). .
Wednesday, November 18th: Northwestern Medical and Sur-
gical Society of New York (private) ; New York State Medi-
cal Association (second day) ; New Jersey Academy of Medi-
cine (Newark) ; Philadelphia County Medical Society (clinico-
pathological).
Thursday, November 19th: New York Academy of Medicine;
New York State Medical Association (third day); Roman
Medical Society, New York (private); New Bedford, Mass.,
Society for Medical Improvement (private).
Friday, November 20th : New York State Medical Association
(fourth day); Chicago Gynaecological Society.
Saturday, November 21st: Clinical Society of the New York
Post-Graduate Medical School and Hospital.
IroceebinfTs of Societies.
NEW YORK ACADEMY OF MEDICINE.
Meeting of November 5, 1885.
The President, Dr. A. Jacobi, in the Chair.
A Sketch of the late Dr. James Lawrence Little was read
by Dr. D. B. St. John Roosa. (See the Journal for November
7th, page 505.)
Electricity as a Therapeutic Agent in Gynaecology. — Dr.
P. F. Muxde read a paper on this subject, pointing out the
scarcity of the literature relating to electricity in gynaecology
and the extensive use to which it might be put with benefit in
various affections, many of which yielded better to this mode of
treatment than to any other. One reason why he had been led
to write the paper was the fact that in electricity we had an
agent which could be employed by any physician with a moder-
ate amount of skill, and which consequently offered relief to a
much greater number of suffering women than methods which
could be carried out only by the specialist. His experience in
this manner of treating the diseases of women was based to a
large extent on empiricism' as indeed was treatment by elec-
tricity in almost all affections in which it was employed. Iu
general he had found the galvanic current of far more benefit
than the faradaic. The latter had a much more restricted field
of usefulness. With regard to the galvanic current, if mild it
answered every therapeutic purpose, and was preferable to the
powerful current which caused pain. A pleasant sensation of
the skin was usually the only sensation which followed its use.
The faradaic current, on the other hand, was usually beneficial
in proportion to its strength. It might be taken as a rule that
when the electrical current increased the pain it was doing
harm, and it should be reduced in strength or discontinued. He
had been unable to decide whether it made any difference, in the
therapeutic results in most cases, whether the negative or the
positive pole was applied externally. He had covered the pole
introduced into the vagina with leather, but an electrician had
told him that this made no difference ; it did not offer any pro-
tection to the tissues. He usually employed the negative pole
to produce an absorbent or alterative effect, using a mild cur-
rent. It was well to begin with a mild galvanic current, from
four to six cells, and with the faradaic current as strong as the
patient could bear without discomfort, increasing the current
gradually. It was well always to introduce the electrode before
closing the circuit, and to diminish the strength of the current
before withdrawing it, thus avoiding producing an eschar or
pain. It should be borne in mind that in many cases the bene-
fit derived from electrical treatment could only be determined
after some time. An exception was where the faradnic current
was employed to bring on the menstrual flow. Sittings should
not take place less frequently than twice a week, and each was
to be continued from fifteen to thirty minutes; it was not likely
that an average of more than two patients could be treated
within an hour. He could say little favorable of this means of
restoring a relaxed condition of the uterine ligaments. In
amenorrhcea, if there was not total absence of molimina, elec-
tricity might be found an efficient mode of treatment, and in
several instances he had employed the faradaic and galvanic
currents alternately with advantage. In girls, temporary ab-
sence of the menstrual flow did not necessarily call for treat-
ment. In women who had frequently borne children, who had
become plethoric, had a sluggish circulation, took little exercise,
and suffered from amenorrhcea, he had found faradism, alone or
alternated with galvanism, a reliable emmenagogue. Frequent-
ly several sittings were required to bring on the flow. In sub-
involution and menorrhagia the faradaic current was especially
indicated. In hyperplasia uteri he relied upon the galvanic
current, frequently repeated and long continued, for diminish-
ing the size and hardness of the uterus, and for relieving reflex
neuroses. In " superinvolution " of the uterus, of which he saw
but little, the electrical treatment would be the same as in
amenorrhcea, the object being to restore the uterus and ovaries
to their normal activity and growth. In pachysalpingitis elec-
tricity and other palliative methods should first be resorted to,
as they would give temporary relief, and time would be given
in which to decide as to the necessity for extirpation of the
ovaries and tubes. In pelvic lymphangitis, chronic pelvic cellu-
litis, and pelvic neuralgias, local or reflex, the electrical treat-
ment should be by the galvanic current. When these conditions
were acute or subacute, electricity should not be employed, as
it would be liable to excite fresh exudation. In neuralgic dys-
menorrhcea, without great obstruction to the menstrual flow, he
had produced benefit, after trying other means in vain, by intra-
uterine galvanization, employing the negative pole internally.
In uterine displacements, greater improvement would probably
follow the faradaic current in flexions than in versions, for elec-
tricity exerted little influence upon the elongated uterine liga-
ments. In fibroid tumors of the uterus electricity had a future,
but, as to ovarian tumors, laparotomy was safe and reliable.
The following were some of the author's conclusions: 1.
Electricity locally applied was a valuable agent in gynaecological
practice, and should be more widely used. 2. It did not re-
quire great experience to be able to use it efficiently in gynae-
cology. 3. Correctly used, on proper occasions, it could do no
harm. 4. It should be used only in chronic conditions; the
galvanic current should not cause pain. 5. The faradaic cur-
rent was indicated where there was deficient development or
want of tone in the genital organs. The object of the faradaic
current was to stimulate the organs to increased growth and
activity. 6. The galvanic current was employed to promote
absorption, to allay pain, to excite retarded action, and occa-
sionally as a caustic. The use of the galvanic cautery, how-
ever, was not discussed in the paper. 7. Perseverance with
the treatment was necessary to success. 8. Subacute and acute
affections generally contra-indicated the employment of elec-
Nov. 14, 1885.J
PROCEEDINGS OF SOCIETIES.
553
tricity. 9. This treatment was often successful when other
forms of treatment could not be borue by the patient. Finally,
in some conditions in which we could hardly hope for a cure,
electricity would give great relief from pain and temporary im-
provement without causing danger or discomfort to the patient.
Dr. Freeman, of Brooklyn, said his experience coincided in
nearly every particular with that of the author. He had em-
ployed electricity in gynaecological practice for twenty years,
first using the faradaic current, then the galvanic, and during
the past four years static electricity. Static electricity was
much more conveniently applied, especially as it did not involve
the necessity for disrobing. One of the greatest advantages of
electricity was its power to allay pain ; in many cases it could
be substituted for opiates. In many instances patients who
were suffering from pain were relieved almost immediately after
occupying the insulated chair. With regard to fibroid tumors
of the uterus, the author had mentioned one of his cases. In
another the tumor was in front of the uterus, the needle con-
nected with the electrode was driven into it through the ab-
dominal wall while the patient was anaesthetized, and a current
from thirty-two cells was passed during little more than half an
hour. There was no severe reaction, but, owing to the delicate
condition of the patient, a second application was postponed a
month or longer, when the tumor was found greatly softened.
There were three applications altogether, and four months after
the first one the patient was able to attend to her household
duties, the tumor having almost entirely disappeared. The
speaker also related another case of fibroid tumor treated suc-
cessfully in this manner, and said he had several others under
progress at present.
Dr. A. D. Rockwell could confirm in very great part the
statements made by Dr. Munde. While electricity was not a
panacea, it had a wide range of usefulness. But it needed to
be employed with care. He supposed that in subinvolution of
the uterus the galvanic current would be more serviceable than
the faradaic. He could not see how any gynaecologist could get
along without electricity in the treatment of pelvic cellulitis.
Dr. H. J. Garrigues could not speak from great personal
experience, but he had employed electricity to a limited extent
during the past thirteen years, particularly in amenorrhoea. But
even here, and in cases of a functional nature only, it did not
always fulfill his expectations; something which acted in merely
a mechanical way would probably do as well. He had found
that the galvanic current was liable to cauterize the vagina, even
where no more than six cells were employed.
Dr. W. R. Birdsall, speaking from a general rather than a
gynaecological experience, thought that what was said with regard
to this therapeutic agent in most books was unsatisfactory, if not
mystifying. Much better results would be obtained if more exact
methods were employed. For instance, it was important to
know the exact strength of the current passed. While most
physicians might be able to employ it with advantage, it was
still true that, the greater the skill and experience, the more likely
would be the success. Among the contra-indications to the use
of electricity were acute and subacute forms of disease. The
effects of electricity, particularly of the faradaic current, were
transient, and the applications should be repeated frequently.
Dr. Malcolm McLean thought electricity should be tried
more thoroughly in cases supposed to call for Tait's operation.
He laid stress upon this point because probably at least fifty per
cent, of the so-called cures after Tait's operation were only
temporary.
Dr. II. J. Boldt had effected a permanent cure by the alter-
nate use of faradaic and galvanic electricity in two cases of met-
rorrhagia and subinvolution of the uterus in which trachelor-
rhaphy had failed.
The President remarked that the importance of a paper
upon this subject was evident from the fact that the three latest
works in German on diseases pertaining to women failed to men-
tion the word electricity.
The discussion was closed by Dr. Munde, who said that sev-
eral of the points raised in the discussion had been dwelt upon
in the paper, but the lateness of the hour bad induced him to
pass them by.
The President announced that, owing to illness, Dr. Jane-
way would be unable to read the anniversary address at the sec-
ond meeting in November, and that Dr. H. D. Noyes had kindly
consented to act as orator on that occasion.
NEW YORK SURGICAL SOCIETY.
Meeting of October 27, 1885.
The President, Dr. Robert F. "Weir, in the Chair.
A Simple Fracture of the Patella treated by Wiring the
Fragments; a Second Fracture treated by Suturing the
Fragments with Catgut.— Dr. L. A. Stimson presented a man,
twenty-one years of age, in whom he had had the opportunity of
observing the condition of the knee joint two mouths and a half
after the patella had been wired for a simple fracture. The
patient came to Bellevue Hospital last June with simple fracture
of the patella, and was treated by one of Dr. Stimson's colleagues
by making a transverse incision and wiring the bone with silver
wire, t«o sutures being inserted. The case did perfectly well,
and the patient recovered without any elevation of temperature
or manifestation of trouble in the joint. When Dr. Stimson first
saw him, two months and a half after the operation, the frag-
ments were closely united, without independent mobility, and
the patient was walking about the wards with a condition of the
knee which allowed the joint to move through the arc of a circle
of about 20°. About one week afterward, while descending the
stairs without falling, stepping down with the sound leg for-
ward, he fractured the patella which had been broken. Pre-,
vious to the accident Dr. Stimson had noticed what seemed to
be one of the wire sutures which could be felt under the skin,
and the patient had felt a slight pricking pain at that point
throughout the progress of the case. In the second fracture the
old cicatrix was torn open. Dr. Stimson enlarged the wound^
and found that the second fracture had taken place exactly in
the line of the first ; one wire was entirely, the other almost
entirely, loose in the wound, and the site of each was marked
by small cavities in the fragments. The surfaces of fracture
were not so rough as usual, and Dr. Stimson thought that union
had taken place, in part at least, by a very thin intermediate
layer of fibrous tissue. On the inner corner of the upper frag-
ment, where in the first fracture there had been a small loss of
tissue, there was a distinct fibrous band, as large as his little
finger. On wiping out the blood he saw a membrane of new
formation underlying the patella, and entirely separating the
fracture from the cavity of the joint, except at one point, when'
it was torn for half an inch ; through this opening he was able
to see false membranes within the joint connecting the condyles
of the femur with the tibial head. He cleansed the wound,
brought the fragments together with catgut and closed the
wound, and the patient was now well. The fragments had
again united, and there was some mobility in the joint. It was
now two months since the second fracture. The reason Dr.
Stimson reported the case was because he had seen not long ago
the statement that there was no case known where any mem-
branes of new formation had formed in the joint after wiring of
the patella for simple fracture. But this joint was full of them,
and they had formed without any inflammatory reaction or any
symptoms indicating their formation. Again, it has been stated
554
PROCEEDINGS OF SOCIETIES.
[N. Y. Mm Jo n(.,
that a patient with a fracture of the patella treated by wiring
could be dismissed cured at the end of four weeks. Dr. Stiinson
did not know of any other similar fracture which was perfectly
sound at the end of so short a period of time, but here was a case
in which two months and a half had elapsed since the fracture,
which had done well, and which, if reported two or three months
ago, at the stage at which most cases had been reported, would
probably have been cited as another example of the safety and
value of the method of treating by wiring, and yet the union
proved not to be strong enough to bear the weight of the body
in descending stairs, and the joint did not allow of more than
20° or 30° of flexion.
Dr. 0. K. Briddon asked if catgut had been used for this
purpose before.
Dr. Stimson said he had used it several times in operations
upon joints. He thought it would Inst probably three weeks.
Dr. W. T. Bull asked what the ultimate prospect was, so far
as motion was concerned in this joint.
Dr. Stimson answered that it was poor.
Dr. Bull asked if that was not generally true in cases in
which the patella was wired.
Dr. Stimson had not seen good motion in any case, but it
had been reported that the operation gave good motion.
Dr. A. C. Post asked whether, if the choice was between a
stiff and a weak joint, the stiff joint was not to be selected.
Dr. Bull thought it was.
The President asked if it was not true also that, after frac-
ture treated by the ordinary method, better results were obtained
than in the joint of the patient presented.
Dr. Stimson replied that a good deal better results were ob-
tained.
Tubercular Disease of the Tarsus ; Resection of the As-
tragalus and Scaphoid Bone. — Dr. Bull presented a young
woman in order to show the result of an operation which had
been performed eighteen months before. She presented herself
at the New York Hospital on the 17th of March, 1884, with the
history that she had been in somewhat delicate health, having
bad cough but no haemoptysis. Seven weeks before admission
she complained of lameness in the right foot and inability to walk
without considerable pain. The motions of the ankle were nearly
perfect. The only evidences of disease of the bones of the tarsus
were a decided tenderness over the scaphoid and a slight swell-
ing below the ankle, and, besides, there was atrophy of the calf
upon that side, which was one inch smaller than its fellow. For
seven weeks the foot was treated with a plaster-of-Paris splint
and applications of oleate of mercury, Paquelin's cautery, bel-
ladonna liniment, etc., without improvement. Dr. Bull then
made an incision upon either side of the ankle and removed the
astragalus and the scaphoid bone. He did not detect any indi-
cations of tubercular disease of the synovial membrane, but the
bones were softened. They were removed entirely with knife
and scissors. The wounds healed promptly, with the exception
of the sinuses left by the drainage-tubes, which were somewhat
slow in closing. In about a month she was able to walk about
and bear some weight upon the foot, but with considerable pain.
Five months later he discovered a good deal of tenderness over
the os calcis and suspected similar disease of that bone, and,
although the motions at the ankle joint were quite good, he
introduced a drill by means of the dental engine into both mal-
leoli, and also into the os calcis. In the former he found no evi-
dence of disease, but in the latter he found a soft spot, which he
drilled out and treated with iodoform, and it healed promptly.
This operation was performed eight months after the first one,
and since that time the pain in the ankle and loot had gradually
disappeared. Now the functions of the foot seemed to he per-
fectly performed, and tho only deformity was a shortening of
the foot by about one inch. The calf of the leg had increased
in size until it was only half an inch smaller than the other.
Unfortunately, as regarded a positive diagnosis, the bones were
lost and therefore not examined for micro-organisms, but, al-
though they did not present to the naked eye any of the charac-
teristic appearances of tubercular lesion, Dr. Bull felt warranted
in believing that the disease was of that nature. It might be
remembered that at a meeting of the society last spring he had
presented a patient, an Italian, from whom he had removed the
entire tarsus for tubercular osteitis. The result had not seemed
to be satisfactory, as the man experienced some pain in walking.
His condition had improved materially since that time, and he
was able to do all sorts of active work without discomfort.
Dr. H. B. Sands thought that the results in cases of excision
of the tarsal bones were usually better than might be antici-
pated; and the observation made by Dr. Bull, that the patients
continued to improve for a considerable period after the ©[(('ra-
tion, accorded with his own experience. In cases of tubercular
disease of the joints in which operations for the removal of a
diseased bone were performed by means of a sharp spoon he
supposed that frequently a sufficient amount of periosteum was
left to reproduce, to a considerable extent, the bone removed,
and in this manner to contribute to the stability of the foot.
He had repeatedly noticed, after thus dealing with the tarsal
bones, and also after removal of the carpal bones, that, although
a large portion of osseous tissue was removed, after the lapse of
six months or a year the parts became so firm that one could
hardly believe that such an amount of bone had been taken
away.
Dr. C. T. Poore said that, in cases occurring in children
where he had endeavored to remove the os calcis and leave a
portion of the bone with the periosteum, he had subsequently
been obliged to remove the entire bone because of non-closure
of the wound, and because the disease was extending to other
bones. In one case he had been certain that he left the ante-
rior portion of the bone undisturbed. Eight or nine months
after the first operation he found the cavity, as it were, of the
os calcis filled with dense fibrous tissue. In children he had not
been able to save any of the bone, but had removed everything,
and the results had been very good.
Stricture of the (Esophagus ; Internal (Esophagotomy. —
Dr. Sands presented a woman, twenty-one years of age, who
had come under his observation one year ago last June. She
was sent by Dr. Paddock, of Dalton, Mass., on account of a
stricture of the oesophagus, which was the result of the acci-
dental swallowing of a solution of caustic potash when she was
two years old. Dr. Paddock stated that he had been called to
see the patient on account of dysphasia, and that she was una-
ble to swallow solid food, and was badly nourished. He de-
tected a close stricture through which he could pass only the
smallest bougies. When she came to Dr. Sands he was able to
confirm the diagnosis made by Dr. Paddock, and found a stric-
ture situated seven inches from the incisor teeth, through which
he could introduce a French catheter, No. 12. He endeavored
to dilate the stricture, and succeeded in carrying the dilatation
up to No. 23 French, but was unable to accomplish more.
Therefore, on the 9th of July, 1884, he introduced the cesopha-
gotome which he had already shown to the society, passed the
bulb beyond the stricture, projected the blade 2 5 mm., and
then withdrew it, making an incision in the posterior median
line of the oesophagus. Immediately after the operation, which
was performed without an anaesthetic and was attended by no
haemorrhage, he passed a No. 29 (French) bougie. Subse-
quently he carried the dilatation up to No. 34 (French). Alter
the cutting operation, instruments were at first passed every
second or third day, and during the summer and autumn at in-
Nov. 14, 1885.]
PROCEEDINGS OF SOCIETIES.
555
tervals of three weeks. In December the interval between the
introductions of the bougies was increased to one month, after
the 1st of January to two months, and now there had been an
interval of three months, without any diminution in the caliber
of the oesophagus at the point where it had been divided. Soon
after the operation, exploration of the oesophagus revealed the
presence of another stricture, ten inches from the incisor teeth,
which admitted a No. 24 (French). Dr. Sands dilated this
stricture, and carried the dilatation up to No. 29, but beyond
this he had been unable to dilate it. He then demonstrated the
lower stricture, and showed that the upper stricture allowed a
bougie No. 34 to pass, while the lower one arrested instruments
larger than No. 29.
The reason why he presented the patient was because he
thought it desirable to correct the common impression that all
strictures of the oesophagus exhibited an invincible tendency to
recontraction, and that the operation of internal division was
unsatisfactory because it was not likely to produce any perma-
nent good result. It so happened that he had received this
evening a communication from the friends of a child upon
whom be had performed several operations of internal ceso-
phagotomy two years ago, for the relief of a stricture of the
oesophagus, and whose case he bad already reported to the so-
ciety. In that instance dilatation was carried up to No. 29.
The child improved in health, was able to eat solid food, and
had remained well ever since. At the present time she swal-
lowed as well as other children, yet no bougie had been passed
since last May. Dr. Sands cited these facts in order to prove
that internal oesophagotomy might sometimes produce results
which were permanent ; and that, although the oesophagus
might not be restored to its normal dimensions, it did not neces-
sarily tend to contract below such dimensions as would permit
of easy deglutition. He had been led to desist from doing more
in the case of the patient exhibited this evening, because she
was in good health, had increased in weight from ninety-six to
one hundred and nine pounds, and was able to swallow liquids
without difficulty, and, with care, to swallow solids when well
masticated.
Strictures of the oesophagus closely resembled strictures of
the urethra, in which there were found every grade of constric-
tion and also a vast difference in the amount of tissue which
caused it. He had seen a case of stricture of the oesophagus in
which the entire tube was converted into a rigid canal. Under
those circumstances no operation whatever could succeed in
restoring a fair amount of dilatability of the oesophagus ; but he
believed that, in many cases, strictures were limited to a very
short part of the canal, and in those cases he imagined that
internal oesophagotomy would be likely to be followed by the
greatest relief with a minimum amount of risk.
Dr. Stimson asked why a further operation was not done
upon the lower stricture in the patient presented.
Dr. Sands replied, only because it seemed already large
enough to allow of the easy deglutition of masticated food, and
also because it had not shown any tendency to contract below
the caliber of No. 29. He was, moreover, inclined to refrain
from cutting the lower stricture, for the reason that it was re-
lated to more important parts than the upper one ; therefore
any accident in the operation might be more serious in its re-
sults. He imagined that the caliber of the (esophagus might be
restored to its normal size, but he did not feel warranted in
doing more than seemed absolutely necessary to render degluti-
tion easy.
Dr. Bull had had occasion to treat one patient, a lady, who
entered the New York Hospital two years ago. The stricture
was about ten inchos from the incisor teeth, and depended, so
far as could be determined, upon a severe sore throat, possibly
diphtheria. It was only with great difficulty that the patient
could swallow anything except water. The stricture admitted
only a No. 8, possibly No. 10, French. By persistent gradual
dilatation the stricture was stretched until, at the end of four
months, it admitted No. 32 or No. 34, French. Dr. Bull saw
the patient up to one year afterward. The bougie was passed
at short intervals during four months, and at intervals of a
month during the remainder of the year, at the end of which
time the condition of the oesophagus was perfectly satisfactory,
as the patient could eat anything which she chose.
Congenital Angioma. — Dr. Charles MoBurney presented
a man who had a congenital angioma of unusual size upon the
right side. The tumor was five inches in breadth and four in
depth, and extended from the median line in front to within
three inches of the median line behind. The patient stated that
during early youth and until within the last seven or eight years
the tumor had bled regularly, and that he had lost large quan-
tities of blood, sometimes as much as a quart at a time. Dur-
ing the last seven or eight years he had been very comfortable,
with firm compression of the growth, and had had no haemor-
rhages. Dr. McBurney felt inclined to advise him to continue
with this treatment, and not to have any operation whatever
performed. The tumor was not pulsating at any part, was
venous, and was of the cutaneous and subcutaneous variety,
chiefly the latter.
Epithelioma of the Tongue ; Removal by Kocher's
Method. — Dr. Stimson presented a specimen of epithelioma
of the tongue, for which he had removed almost the entire
organ by Kocher's lateral supra-hyoid method. The patient
was a man sixty-eight years old; the disease extended as far
back as the finger could reach through the mouth, and involved
the floor of the mouth and the gum on the right side from
the median line two inches backward. On the dorsum of the
tongue there was a very large irregular ulcer. Tracheotomy
was done, and the etherization was continued through the tube.
The incision was made on the right side, and the right lingual
and facial arteries were tied in the wound before their division ;
the left lingual was tied through the wound after its division,
and this was the only ligature that was made necessary by the
removal of the tongue. The entire organ, except a strip of mu-
cous membrane at its base, was removed, as was also a portion
of the submental muscles which had become involved in the
disease. The area of raw surface created by the removal was
diminished by drawing the adjoining mucous membrane over it
so far as possible and stitching it fast. The wound was packed
with iodoform gauze, and the mouth frequently cleansed with a
solution of salicylic acid and borax, and the patient had been
regularly fed through an oesophageal tube. The tracheotomy-
tube was removed on the sixth day. The patient was now, on
the sixteenth day, doing well.
Dr. Sands had within the last ten days had occasion to re-
move the lateral half of the tongue on account of a cancerous
swelling situated on the left side of the organ, extending toward
the root but not to the median line. He adopted the method
known as Whitehead's. He etherized the patient, introduced
Wood's mouth-gag, passed a stout ligature through the tongue
upon the right side, drew it forward, divided with a pair of
straight scissors its attachments to the lower jaw and to the floor
of the mouth, split the tongue in the median line toward the
root, then made a transverse cut, dividing the tongue and the
anterior pillar of the soft palate, and completed the operation
with the loss of only about eight ounces of blood. He had but
little difficulty in applying a ligature to the lingual artery. He
packed the wound with gauze, aud used a small stomach-tube
for feeding the patient during the first week. The progress
of the case had been entirely satisfactory, the man was now
556
PROCEEDINGS
OF SOCIETIES.
|N. Y. Mkd. Jock.,
able to swallow, and was convalescent. Dr. Sands was very
much impressed with the excellence of the method in those
cases in which the disease was strictly limited to the tongue.
He was sure that the operation could be safely done if the
entire organ required to be removed, and he should prefer to
perforin this operation rather than that which included a pre-
liminary ligation of one or both lingual arteries.
Dr. Beiddon asked if the difficulty in securing the arteries
would not be greater in Whitehead's operation.
Dr. Sands replied that the operation did not consist in cut-
ting off the tongue at once, but in making short strokes and
tying the arteries as they were divided. Of course the cases
should be selected in which the operation was especially ap-
plicable.
The President remarked, with regard to Kocher's opera-
tion for removal of the tongue well back, that it had pleased
him most on account of the thoroughness with which all dis-
eased tissue could be removed.
Necrosis of the Os Brachii without the Formation of
ail Involucrum. — Dr. Post presented a specimen of necrosis
of the os brachii without any attempt at the formation of an
involucrum. It was removed from a boy twelve years of age,
with the history that between one and two years ago he was
bitten by a spider, and that the bite was followed by very severe
inflammation. A number of months afterward extensive sup-
puration occurred about the joint, and Dr. Post performed ex-
cision of the elbow. Subsequently he found that the wound at
the joint had healed, but that there was suppuration higher up,
with loss of continuity in the bone of the arm nearly as high
as the middle. Recently he cut down upon the bone and found
that its lower extremity was necrosed to the extent of 65 mm.
on one side and 35 mm. on the other. The dead bone was
lying loose in the midst of granulations. The inferior ex-
tremity of the living bone above presented a jagged extremity,
but was not bare to any considerable extent. He did not re-
member any other instance in which necrosis of a long bone of
an extremity had occurred without the formation of an involu-
crum, except in a case of necrosis of the fibula, also in a boy,
in which the tibia was not involved. In that case the fibula,
for its whole length except the two articular extremities, was
in a state of necrosis, and there was no involucrum. The tibia
formed a support for the limb, so that there was no false point
of motion.
Dr. Stimson thought that something besides simple necrosis
had occurred in the bone presented, as it was filled with bony
deposit, and that the shell had disappeared by absorption.
Dr. Post remarked that the whole process was different
from the ordinary process of necrosis, but the bone was evi-
dently dead.
NEW YORK NEUROLOGICAL SOCIETY.
Meeting of October 6, 1885.
The President, Dr. W. R. Birdsall, in the Chair;
Dr. G. W. Jacoby, Secretary.
Dr. M. A. Starr, Dr. I. Adler, Dr. J. B. Emerson, Dr. R. M.
Cramer, and Dr. R. G. Wiener were elected to membership. '
A Contribution to the Pathology of Hemianopsia of
Central Origin. — Dr. E. C. Seguin read a paper with this title.
He first gave a brief synopsis of views, anatomical and patho-
logical, of hemianopsia of basal or peripheral origin, recogniz-
ing the following types: 1. Horizontal hemianopsia, superior or
inferior, usually due to lesions within the eye, and hence of
comparatively little interest to the neurologist. 2. Vertical
hemianopsia, always caused by a lesion of the basal visual ap-
paratus or by disease in a certain limited part of the cerebrum.
Its varieties were: a. Temporal hemianopsia, in which the tem-
poral half of both visual fields was dark. b. Nasal hemianopsia,
in which the nasal half of both visual fields was obscured, c.
Lateral hemianopsia. This was often designated homonymous
hemianopsia. In this variety the nasal half of one visual field
and the temporal half of the other were dark, so that, with one
or both eyes open, the patient saw the same half of any object
placed in front of him. This variety was the one which resulted
from a truly central lesion, and formed the subject of study in
the paper. Varieties a and b were caused by lesions variously
placed in or around the chiasm of the optic nerves.
The author proceeded to analyze the recorded observations
of hemianopsia due to cerebral lesion, forty-two in number, in-
cluding his own case. Of these, thirty-seven were medical and
accompanied by autopsies; five surgical, followed by survival of
the patient. These relatively numerous observations were clas-
sified as follows: A. Cases of lateral hemianopsia, indefinite or
irrelevant, and useless for localization study, fifty-four in num-
ber; observed by Charcot and Pitres, Linnell, Wiethe, and Pe-
trina. B. Cases of lateral hemianopsia from lesions of parts of
brain not directly related to the optic apparatus, three cases;
by Ilirschberg, Iluguenin (obs. of 1870), and Pfliiger. C. Cases
of lateral hemianopsia from lesions involving chiefly the thala-
mus opticus or corpus geniculatum laterale, six in number; by
Jackson and Gowers, Pooley, Dreschfeld (three cases), and Ro-
senbach. D. Cases of lateral hemianopsia from lesions chiefly
or exclusively involving the white substance of the occipital
lobe, eleven cases; by Levick, Hosch, Baumgarten, Dmitrow-
sky and Lebeden, Westphal (1881), Senator, Sturger (Case vii),
Wernicke and Ilahn, Jany, Richter, and Schmalz. E. Cases of
lateral hemianopsia of external or traumatic origin, five cases;
by Keen and Thomson (re-examined by Dr. Seguin), Hughes,
Schmidt -Rim pier, Heuse, and Nieden. F. Cases of lateral he-
mianopsia due to lesions involving the cortex of the brain and
subjacent white substance, thirteen cases ; by Westphal (1882),
Stenger (Case viii), Forster and Wernicke, Jastrowitz (two
cases), Curschmann, Nothnagel, Marchand, Chaillou, Haab, Hu-
guenin (1882), Fere, and the author.
This last category being by far the most important for the
study of the localization of the visual center in man, Dr. Seguin
gave full abstracts of all these cases. The lesions in all were so
placed as to cumulate toward the mesal aspect of the occipital
lobe. This r»sult was shown by means of a shaded chart, con-
sisting of a diagram of the mesal and lateral views of the brain,
upon which the lesions of the thirteen cases were reproduced
and with one layer of India-ink. The result was striking, visi-
ble in the greatest blackness of an area upon the mesal aspect
of the cerebrum, including the lower part of the cuneus and the
fifth temporal gyrus (Ecker). To this locality also was limited
the lesion found in the following cases: Haab's, Huguenin's,
Fere's, and Seguin's. These were single lesions, and no paraly-
sis or anaesthesia had been observed during the patient's life —
only hemianopsia.
Dr. Seguin's own case was as follows: A man, aged forty-six, affect-
ed with malignant endocarditis (mitral vegetations) which proved fatal
in sixteen months from first observation, in January, 1884, through re-
peated visceral embolisms. This patient also exhibited for many weeks
an exquisite intermittent form of fever, closely imitating malarial inter-
mittent. About December 5, 1884, Mr. D. suddenly complained of
" blindness of the left eye," and slight numbness through the whole
left side of the body. He strongly insisted then, and frequently there-
after, that his left eye was alone affected, because he could not see to
his left. Examination showed well-defined left lateral hemianopsia, the
vertical line passing a little to the left of the point of fixation. In a
short time the numbness passed away, but the hemianopsia persisted
until death. For many months before death Mr. D. was able to read
Nov. 14, 1885 J
PROCEEDINGS
OF SOCIETIES.
557
and write easily and attend to business outside, in spite of the hemian-
opsia. The lesion found at the autopsy was a large old patch of yellow
softening, involving the greater part of the right cuneus (almost reach-
ing the apex of the occipital lobe) and the fifth and fourth temporal
gyri, extending also frontad into the gyrus hippocampi. This lesion
was found to be due to a blockade of the occipital branch of the poste-
rior cerebral. The white matter was involved to a depth of several
millimetres. No sections were made in the fresh state of the specimen,
in order to prepare it for more careful examination when hardened.
Unfortunately, this process was unsuccessful in part, and only the oc-
cipital end of the brain became hard. The absence of decided motor
and sensory symptoms during life, however, made it quite certain that
there were no other gross lesions in the brain.
From these four cases, supported by the cumulative evidence
of all the others, Dr. Seguin considered it well proved that the
visual center (receiving impressions from one corresponding half
of each retina) in man was in the cuneus and adjacent gray
matter below it. A destruction of this part of the hemisphere
inevitably produced lateral hemianopsia of the field on the oppo-
site side of the body. As regarded those few cases in which the
lesion causing lateral hemianopsia was situated upon the lateral
aspect of the hemisphere, in the inferior parietal lobule and the
gyrus angularis, Dr. Seguin called attention to the fact that the
optic fasciculus of Gratiolet and Wernicke on its way from the
primary optic centers, laterad of the posterior horn of the lat-
eral ventricle, to the cuneus, passed close under these gyri, and
a lesion which penetrated at all beneath the gray matter of their
cortex must intercept the optic fibers, by pressure or by destruc-
tion. These were lesions intercepting communication between
the eyes and the visual center, while lesions of the mesal aspect
of the occipital lobe destroyed the center itself.
Dr. T. R. Pooley, without knowing at all the direction
which Dr. Seguiu's paper would take, had hastily looked over
his records before coming to the meeting, and briefly abstracted
five cases of hemianopsia of which he had notes. One of these
cases had been referred to in the paper. The speaker felt quite
incompetent to discuss the physiological and theoretical ques-
tion as to the location of the lesion, and the importance of dif-
ferent symptoms in helping to exactly locate the lesion in the
brain. He had intended to relate clinical histories somewhat in
detail, but would content himself with speaking only of one
case, which had recently come under his observation and in
which the patient was now under treatment. It was one that
he had seen a week before — that of a gentleman, aged thirty-five
years, who had been under his care in 1879 for comparative
blindness of his left eye, which had been found to be due to cir-
cumscribed choroidal exudation situated near the macula lutea.
From his former observation of such cases, the speaker had al-
ways believed them to be due to syphilitic infection, and care-
ful inquiry into the history of this case showed it to be due
also to this poison. The patient remained for a time under
treatment for this inflammatory exudation, from which he re-
covered with a scotoma, and enjoyed comparatively good health
and freedom from all further syphilitic manifestations until a
week ago, when he consulted the speaker again. On this occa-
sion he was driving with his wife in the country when he sud-
denly became completely blind. This blindness lasted only a
few moments. Upon recovering, he ascertained that there was
dimness of vision upon the left side, which continued when he
came to see the speaker. Examination showed left homony-
mous hemianopsia, the blind area extending almost to the point
of fixation in each eye. Examination of the acuteness of vision
showed that of the left eye (and this was interesting because of
the previous condition of that eye) to be ff„, that of the right
eye being f£, or perfect. The optic discs were quite normal, the
blood-vessels were of full size, and there was no indication of
atrophy of the optic nerve by neuritis. The interesting and re-
markable fact in this case was the improvement which took
place within a week from the commencement of treatment. On
account of the previous history of the case, the patient was given
large doses of iodide of potassium. The first day after treat-
ment had been begun the visual fields had increased in extent,
and this increase had steadily continued until the present date.
Unfortunately, there had been no opportunity to make measure-
ments with the perimeter, the patient being treated at his
home, but the speaker estimated that the field of vision had ex-
tended from near the point of fixation to one third the normal
limits, the increase being apparently symmetrical. He would
like very much to have Dr. Seguin's opinion as to whether in a
case of this kind, in which there had been such marked im-
provement within a week, we might hope for permanent benefit.
Dr. M. A. Stake thought that the list Dr. Seguin had pre-
sented was a complete one with perhaps a single exception, that
of a case reported by Demange, in the " Revue de medecine "
for May, 1883. That case was referred to by Dr. Gowers in his
last work on diseases of the brain in a way to lead one to suppose
that it supported the assertion of Ferrier that the angular gyrus
was the center for vision. The speaker had found, however, on
looking up the case, that the lesion was one which coincided
very largely with that of Westphal's first case, and it was very
well represented by the diagram of that case shown by Dr.
Seguin. It was a very large lesion, involving botli parietal
lobules and the occipital lobe. Gowers referred to that case as
proving that a lesion upon one side of the brain might produce
blindness of the opposite eye, and said it supported Ferrier's
assertion of amblyopia being due to lesion of one angular gyrus.
In the original report, however, it had only been stated that the
patient could not see well with the lett eye, and not that there
had been any careful measurement of the field of vision. There-
fore in all probability the patient had hemianopsia, and, as in a
number of cases reported by Dr. Seguin and in a number
which the speaker had collected, from lack of careful observa-
tion, the examining physician had failed to elicit the symptom
which was undoubtedly present. The necessity for careful ex-
amination in all these cases had been dwelt upon by Dr. Seguin,
and it ought to be emphasized, because it was evident from the
histories of these cases that a patient with hemianopsia did not
notice the exact field of vision, but only noticed that he was
blind in one eye, and referred it to the eye of which the field of
vision was the more largely implicated. The necessity for such
an examination was shown in the fact that Dr. Seguin had been
able to collect eight cases in addition to those which the speaker
had collected, so that eight new cases had occurred since Janu-
ary, 1884. This great increase in the number of cases of hemia-
nopsia was only apparent, few cases having been recorded previ-
ously because of imperfect examinations of the visual field. He
would not anticipate Dr. Seguin in answering the question asked
by Dr. Pooley, but he had in hand a case, published by Baer in
Volkmann's "Sammlung klinischer Vortrage," which was al-
most identical with that related by Dr. Pooley this evening — a
case of hemianopsia coming on suddenly in a syphilitic individ-
ual. A series of diagrams was given, showing the progressive
improvement of the patient and his final complete recovery.
The speaker's attention had first been called to this subject throe
years ago by seeing a case of hemianopsia in Charcot's wards,
and in his lecture on that case Charcot virtually retracted his
own diagram and adopted one like that shown by Dr. Seguin.
So that we should cease to copy the old diagram made by Char-
cot, as it had been abandoned in France and Germany. The
absolute necessity for such a collection of cases as Dr. Seguin
had made, for settling any disputed question of localization, was
perfectly evident. It was the only way in which this question
558
PROCEEDINGS OF SOCIETIES.
[N. Y. Mhd. Joi r.,
of localization could be really determined. To draw conclusions
from physiological experiments was no longer warranted. We
must go to carefully-made autopsies. It might be interesting to
know that in October, 1858, the Pathological Society of Phila-
delphia discussed the subject of abscess of the brain, and that at
that meeting Dr. Weir Mitchell presented a case, with the rec-
ords, in which a large abscess at the posterior part of the brain,
involving both occipital lobes, was attended with blindness, and
the blindness seemed to be the chief local symptom (as we
should say now) of the disease. The. Pathological Society was
at a loss to explain the occurrence of blindness with this lesion
in the occipital lobes. It was encouraging to the general cause
of clinical diagnosis that now, after the lapse of these years, we
were able to explain perfectly the case which then so puzzled
that society.
Dr. Seguin closed the discussion with reference to Dr.
Pooley's question. lie could not answer it, for want of experi-
ence. He had never seen a case of hemianopsia which was not
embolic, or possibly due to a tumor, in which there was no in-
dication for treatment.
NEW YORK COUNTY MEDICAL ASSOCIATION.
Meeting of October 19, 1885.
The President, Dr. Charles A. Leale, in the Chair.
Fracture of the Patella.— Dr. Frederic S. Dennis read a
paper in which he weighed the arguments for and against wir-
ing of the separated parts of the fractured patella. Surgeons
were divided in opinion with regard to the merits of this meth-
od of treatment, some maintaining that it was perfectly justifia-
ble, and, under strict antiseptic precautions, free from danger.
On the other hand, it had been said that, previous to 1883, two
cases had terminated in death and several in ankylosis. But a
study of the statistics since 1883 showed a great diminution in
what was then a small mortality, and a great decrease in the
number of cases which had resulted in suppuration and anky-
losis. Dr. Dennis had collected about twenty-three cases since
1883, exclusive of those which had occurred in Rellevue Hospi-
tal. According to a general estimate there were as many as
fifty cases, and in none, so far as could be ascertained, had death
occurred after this mode of treatment if but a simple fracture
existed. In three of the fifty cases suppuration occurred, but
one of the three was a case of compound fracture. In this, as
in all other important operations, failure would occur now and
then, even in the hands of the most skilled and circumspect sur-
geons. Those who opposed the operation based their opposition
on a supposed risk of opening the knee joint and on the assumed
fact that equally good effects could be obtained by less heroic
means. As to the good results alleged by those who advocated
older methods of treatment, careful analysis of a large series of
cases proved that, as regarded the condition of the joint and
the character of the union, they were unsatisfactory; that they
were much inferior to the excellent results obtained by the use
of the metallic suture. During the last five years Dr. Dennis
had treated sixty cases of fracture of the patella, and until re-
cently had used old appliances, particularly plaster of Paris as
it was employed by the late Dr. Little. The results in the great
majority of cases had been unsatisfactory, particularly as con-
trasted with those obtained by wiring the fragments. That
bony union was possible, however, without the suture, was evi-
dent from a specimen presented. When Sir Joseph Lister was
asked why he wired the fractured patella, he said his first rea-
son for doing the operation was that it, relieved muscular spasm
in the quadriceps, and the second that it permitted the escape
of blood from the joint. In the debate it was asserted that
tenotomy would accomplish the first object, and aspiration the
second. Sir Joseph then replied that it was because he had
such faith in his antiseptics. A more substantial and cogent
reason would be that the operation was comparatively free from
danger, and, while it relaxed muscular spasm and permitted of
the escape of blood from the interior of the joint, insured in
every case osseous union of the fragments, and, as a natural con-
sequence, unrestrained movement in the joint. The reason why
osseous union was not obtained when the wire was not em-
ployed was, that the aponeurotic fascia falling between the
fragments prevented union. Until this fascia was removed from
between the fragments, which could only be done by opening
the joint, osseous union was not likely to occur. There were
three arguments in favor of this operation as against other
methods of treatment, which the author thought could be sub-
stantiated : 1, The absence of danger to life and limb ; 2, supe-
rior results as regarded function of the limb and joint; 3,
greater rapidity of repair. The mortality prior to 1883 was at-
tributed to the fact that the operation was in its infancy. Since
then improved methods of performing it had enabled the opera-
tor to conclude the operation in not more than thirty minutes.
Formerly two hours were often consumed, principally in drill-
ing the holes and passing the wire; now, with the Archimedean
drill, the holes could be made in four seconds. No one ques-
tioned the superiority of the method over all others in cases of
compound fracture. A patient was presented who had had
compound fracture; no constitutional symptoms developed, and
he was enabled to walk well within eight weeks; he could run
up stairs and dance as well as before the injury. A specimen
was presented which was removed from the body of a patient
dead of delirium tremens and Bright's disease six days after a
fractured patella bad been wired. The joint was aseptic, there
were no indications of suppuration, and bony union was suffi-
ciently strong to have enabled the patient to walk without sepa-
rating the fragments. Union did not take place by callus, but
by primary intention, as it would in the soft parts. As regarded
superiority of the results over those of other methods, there was
no separation of the fragments, but bony union ; no ankylosis,
no pain, no crutches, no knee-cap, no posterior splint, no liabili-
ty to refracture unless by direct violence, no fear of falling, no
difficulty of locomotion, no synovitis, no oedema of the limb —
none of the chapter of mishaps which were likely to happen
under the older method of treatment. As to the greater rapid-
ity of repair, by the older method nearly three months were
consumed in the repair of the fracture, and two years in restora-
tion of the functions of the joint and limb. After wiring of
the fragments the patient had complete use of his limb within
eight weeks, and could safely move about within three weeks.
Wiring of the fragments should not be performed immediately
after a simple fracture, as inflammation would be liable to re-
sult. It wa9 better to wait a few days. After compound frac-
ture the operation should be performed right away. Strict an-
tiseptic precautions should be observed; Dr. Dennis employed
a solution of bichloride of mercury, 1 to 3,000, and kept up irri-
gation during the operation. The operation should not be per-
formed by the ordinary practitioner, nor by a surgeon who had
little faith in the germ theory.
Dr. Fowler, of Brooklyn, to whose cases the author had
alluded, presented some patients upon whom he had wired the
patella in simple and compound fractures. In one case the
separation between the fragments could not be reduced to less
than an inch and a quarter until after he had resorted to the
method advocated by Macewen of cutting a V-shaped piece out
of the quadriceps muscle, when they were approximated w ith
ease. Regarding the ends of the twisted wires, instead of ham-
mering them down, he bent them between the fragments. It
was better, however, to use the bridge suture and remove them
Nov. 14, 1885.]
MISCELLANY.
559
when union had been completed. He had made the holes in the
fragments with a shoemaker's awl, and inserted the wire through
a cannula.
Cultivations of the Micro-organisms of Osteo-myelitis
were demonstrated hy Dr. H. M. Biggs, who showed the Sta-
phylococcus cerveus albus and the Staphylococcus pyogenes au-
reus.
Dr. J. Faure, lately of the French navy, was introduced to
the society, and presented a serve nceud which he had invented.
Nummulites from the pedestal of Cleopatra's needle were
presented by the President.
fjl t s t * 11 a n p ♦
The International Congress. — In its November issue, the " Pacific
Medical and Surgical Journal," of San Francisco, says:
" The only important events regarding the Congress that have tran-
spired since our last issue are the publication, in the ' American Medi-
cal Journal' ['Journal of the American Medical Association'] of a
historical account of all that has been done by the American Medical
Association in this matter since the meeting in Washington, in May,
1884, and the declaration of independence by the Executive Committee
appointed by the Committee of Arrangements at its session two months
ago. In his historical account, the editor of the ' American Medical
Journal ' [' Journal of the American Medical Association '] argues that,
as the Committee of Invitation had been appointed by the American
Medical Association, therefore the association was accountable for all
acts of the said committee. If we could only agree with him in this
one particular point, and be convinced of the validity of the associa-
tion's claim to supremacy, he would receive our most hearty co-opera-
tion in upholding the action of that body against its assailants. Un-
fortunately we can not acknowledge this authority.
" The invitation was presented at Copenhagen in the name of the
' profession in the United States.' We grant it must have been known
in Europe that the idea originated in the American Medical Association,
and that the initial steps were taken by that body ; but this informa-
tion only reached them indirectly, as the name of the association was
not included in the invitation, and should not therefore appear on the
official records of the Congress, which constitute the only laws govern-
ing that assembly. If the association never extended an invitation, we
can not see what right it has to claim the position of host on this occa-
sion; and if the crime of being a 'first cause' is to decide the matter,
then the whole responsibility for the shame and disgrace which have
accrued to the American medical profession in connection with this sub-
ject must be laid at the door of that unfortunate being who first agi-
tated it among his medical brethren. Further : According to the cus-
tom of the Congress, the gentlemen presenting the invitation for the
next place of meeting have been regarded as their committee for making
the necessary arrangements, and hence Dr. Billings and his confreres,
so soon as their invitation was accepted, ceased to be the ambassadors
of the ' profession in the United States ' ; they even, in the eyes of the
Congress, laid aside their character as national representatives, and be-
came the servants of that body, intrusted with the duty of making the
necessary arrangements for the meeting of 1887, and selected for this
purpose only because they were resident in the country where that
meeting is (or was) to be held. We have already given the testimony
of Sir James Paget and other prominent members of the Congress in
support of these statements, which prove beyond a doubt that Dr. Bil-
lings's committee, after discharging their duty of presenting the invita-
tion intrusted to them by the profession in the United States, became
responsible to the Congress alone for their future actions in the matter.
"It may be objected that the duties of the committee did not end
with presenting the invitation, because they had full powers from the
association to make all preliminary arrangements. This is just the
point where the American Medical Association overstepped its own au-
thority, and interfered in a matter with which it had no business. The
Congress has its own committee for making its arrangements, and the
fact that the association, either through ignorance or presumption,
endeavored to control this committee, does not by any means transfer
the power from one to the other. This is of much importance, for the
point at issue is : Has the Congress the power of making arrangements
for its own meetings, or does that power lie in the hands of the Ameri-
can Medical Association? The Arrangement Committee is answerable
to either one of these bodies, but not to both ; and the one to which it is
answerable has full power to approve or disapprove of its action. We
have shown that hitherto this power remained in the hands of the Con-
gress. We hoped that the committee would have recognized this fact
at its meeting in September last, and courteously retired from the false
position which they now hold. It is no disgrace for any one to admit
that he has made a mistake, and this certainly would have brought
'peace with honor.'
" We have given this historical account of the working of the Con-
gress to show our readers that this triennial medical convention ante-
dates the meeting of the American Medical Association at New Orleans
in 1884, and has, therefore, some laws and precedents to regulate its
actions. Probably the most startling event in the whole history of this
miserably-bungled affair is the following resolution, passed by the Ex-
ecutive Committee appointed by the Committee of Arrangements two
months ago: 'Resolved, That this Executive Committee enters upon the
management of the affairs of the Ninth International Congress with the
understanding that, in accordance with Rule No. 10, its powers are not
restricted, except by the rules and regulations adopted September 3,
1885, by the Committee of Arrangements appointed by the American
Medical Association, in April, 1885; and that the actions of this Execu-
tive Committee are final, not being subject to revision, amendment, or
alteration, by either the Committee of Arrangements or the American
Medical Association.' We certainly admire this bold piece of policy on
the part of the Executive Committee, but hardly find it consistent with
the opinion which the American Medical Association obtained from Ex-
Speaker Randall, and with which they sought to justify their action at
New Orleans : ' . . . The theory that a select committee, created by a
body with certain defined powers and duties, gives any vested rights, so
to speak, which place it above or beyond the power of the creating body
to review or regulate, is one not only without precedent in parliamentary
law, but is untenable on any ground of parliamentary principle.'
" We have always been in accord with the sentiments expressed in
Mr. Randall's opinion, and never imagined that Dr. Billings and his asso-
ciates constituted an irresponsible committee ; we only held that they
were answerable to the Congress, and not to the national association,
and that any instructions regarding the arrangements issued by the asso-
ciation were invalid, as the Congress has always made its arrangements
through its own committee. But here we have a committee declaring
itself to be irresponsible, a servant without a master. This combination
calmly asserts that it is going to do the work, and that the Congress and
profession generally will accept and approve of that work, whether they
like it or not. Out in California we have had some experience of vigi-
lance committees in troublous times, who were invested by the citizens
with full powers to use all means to quell the disturbance, and this is
the only irresponsible committee known in this State. Possibly this
Executive Committee is of that nature, and has been appointed to carry
out the purposes of Dr. King, of Missouri, who, when Dr. Billings's report
was up for discussion at New Orleans, so eloquently advocated that 'the
specialists of the new-code persuasion should be taken by the top of the
head, and their throats cut at once.' We write in the greatest trepida-
tion, lest from New York the wail of widows and orphans confirm our
worst suspicions."
The " Medical Times and Gazette" says :
" Those of our English readers who have followed with painful in-
terest the course of the struggle now in process in America with regard
to the Washington Medical Congress of 1887 will be amused to hear
that the new Executive Committee of the Congress have resolved that
their actions ' are final, not being subject to revision, amendment, or
alteration by either the Committee of Arrangements or the American
Medical Association.'" The astuteness of that resolution is as remarka-
ble as the irony of it is delicious. If the original committee had only
been wise enough, before the event, to have adopted such a decision,
560
MISCELLANY.
[N. Y. Mkd. Jopr.
there would have been none of the dissensions which have so terribly
distracted the American profession. The resolution is at once a slap
in the face to the American Medical Association and a sneer at the
original committee of eight, as if to say, ' Why, what idiots you were,
not to have thought of this ! ' And yet it is at the same time a score
to the original committee and its supporters in that it is a justification
of their action in resenting the interference of the association with their
decisions. Meanwhile we hear affairs are in statu quo. The resigna-
tion of Dr. Dalton, the chairman of the physiological section, which has
happened since we last wrote on the subject, leaves the organization of
the Congress without a single really scientific representative if we ex-
cept the Flints and Dr. N. S. Davis. If the meeting is held, the sec-
tions of anatomy, physiology, and pathology will not be attended by
any of the American workers in those fields. There is, we fear, little
hope now of an arrangement. All the prominent American men of
science have withdrawn, and will not return unless very considerable con-
cessions are made, of which there appears no hope. The 'Berliner kli-
nische Wochenschrift ' this week roundly states that hardly a single
'medical personage' will be found to undertake the voyage from Ger-
many for the privilege of sitting under the presidency of Dr. Shoe-
maker. It makes, however, a strong appeal to the American Medical
Association to approach the subject in a more wise and generous spirit
when its next spring assembly takes place, and to re-arrange its propo-
sitions in such a manner that the services of the leaders who were
nominated in the first instance may still be made available. In the
absence of such a re-arrangement, our Berlin contemporary expresses a
decided opinion, which we can heartily indorse, that the Congress of
1887 will be foredoomed to dismal failure. The whole thing is a bad
business. It is an awkward position, for it must be remembered that
the Washington Congress will have to make arrangements for the suc-
ceeding meeting. Suppose Dr. Shoemaker and his friends decide that
the Congress of 1890 shall be held in Texas ! "
The Charity Organization Society. — Mr. Kellogg, the organizing
secretary of the society, asks us to give notice that, in compliance with
many requests from officers in charge of medical institutions, the so-
ciety invites the medical staffs and the boards of managers of the sev-
eral hospitals and dispensaries of New York to meet at the Hall of the
Academy of Medicine on Friday evening, November 20th, at 8 o'clock,
to confer together concerning the existing abuses and misapplication of
medical charity, and to consider how these abuses may be remedied
through the registration system and other facilities of the Charity Or-
ganization Society.
The Health of Michigan. — It appears by a summary for the four
weeks ending October 31st, issued by Dr. Henry B. Baker, the secre-
tary of the State Board of Health, that diphtheria was reported from
fifty-nine places, scarlet fever from forty-one, typhoid fever from thirty-
six, and measles from three.
THERAPEUTICAL NOTES.
The Treatment of Expulsive Gingivitis and Osteo-periostitis. —
The frequency with which physicians practicing in small communities,
where the services of a dentist are not always to be had, are called
upon to treat recession of the gums, and the accompanying osteo-peri-
ostitis, has led a French journal styled " L'Odontalgie " (quoted in the
" Gaz. hebdom. de m6d. et de chir.") to summarize the treatment rec-
ommended by Dr. Mailhol, of the Argentine Republic. That gentleman
employs treatment preparatory to medication with iodine, after having
freed the teeth from tartar, especially by means of a collutory made
after the following formula :
Boric acid in fine powder 75 grains ;
Saturated chloroform-water 3 ounces.
Dissolve the boric acid, and add :
Distilled anise- water 3 ounces;
Distilled water 6 "
Shake and filter.
For the treatment of alveolo-dental osteo-periostitis, the author for-
merly used chromic acid, as advised by M. Magitot, but now he agrees
with Dr. Harlan (" Dental Cosmos ") in preferring iodide of zinc. The
cavities are first washed out with the collutory, by means of a syringe,
and then filled with cotton medicated with chloral, glycerin, and a solu-
tion of iodoform in its own weight of chloroform. The pain having
been allayed, and the swelling having disappeared, the affected alveolar
border is removed, and an injection is thrown into the cavity of a few
drops of a solution of iodide of zinc in distilled water (1 to 40 at first,
gradually increased in strength to 3 to 40).
An Ointment for Syphilitic Psoriasis. — The " Union medicale "
attributes the following formula to Mauriac:
Oil of cade, i
Mercurial ointment, \ each 1 Part i
Vaseline 15 parts.
To be used by inunction, morning and evening, for syphilitic psoria-
sis of the palms and soles.
The Treatment of Rheumatic Purulent Conjunctivitis. — In cases
which show the clinical features and the gravity of gonorrhceal con-
junctivitis, but in which the articular manifestations, the history,
hereditary influence, and the absence of any urethral discharge have
established the diagnosis, M. Perrin (Ibid.) advises, in addition to cau-
terizations with a fifty-per-cent. solution of nitrate of silver, the fre-
quent use of a mixture of one part of alcohol to three parts of water,
either as a lotion or in the form of spray. At the same time, anti-
rheumatic medicines should be given internally, especially salicylate of
sodium.
Huchard's Haemostatic Pills. — The same journal gives the follow-
ing formula :
Ergotin, i
Sulphate of quinine, \ each 30 &*inR '
Powdered digitalis, \
Extract of hyoscvamus, \ eacn 3
Divide into twenty pills. Five, eight, or ten are to be given daily,
for various forms of haemorrhage, such as metrorrhagia, epistaxis, and
haemoptysis.
Copaiba in the Treatment of Elytritis. — For various forms of in-
flammation of the vagina, whether due to a specific virus, to local irri-
tation, or to a constitutional condition, M. Baratier (" These de Paris" ;
"Bull. gen. de therap.") recommends the following treatment, which
he has often seen Professor Ball employ : Every second day a supposi-
tory made after the following formula is placed in the vagina, where it
is allowed to remain for twelve hours :
Solidified copaiba, / , H_
' ' V each 75 grains ;
Cocoa butter, )
Extract of opium £ grain.
This mode of using copaiba is said not to produce unpleasant re-
sults. The cure is complete in about twenty days.
The Treatment of Contraction of the Palmar Fascia without Opera-
tion.— M. Costilhes ("Jour de med. et de chir. prat." ; "Lyon med.")
has collected many instances of the success of Vulpian's treatment,
which consists in the prolonged use of this ointment:
Lard or vaseline ... 20 parts ;
Iodide of potassium 10 "
Tincture of iodine 2 "
The ointment should be applied abundantly to the whole surface of
the palm, and the hand should be covered with a thick layer of cotton,
over which several turns of a bandage are applied. The dressing
should be renewed every day until complete desquamation of the palm
is produced. Sometimes the results are very rapid, great improvement
being manifested at the end of a fortnight. Iodide of potassium may
be given internally at the same time, and massage employed.
Lactic Acid in the Treatment of Laryngeal Tuberculosis. — In
view of the general failure of other therapeutical measures, Dr. H.
Krause (Berlin, klin. Wchnschr." ; " Ctrlbl. f. klin. Med.") has taken a
hint from von Mosetig-Moorhof's use of lactic acid for lupus, fungous
caries, etc., and treated laryngeal phthisis with this agent, using solu-
tions of from twenty-five to eighty per cent. He reports a decrease of
the swelling and infiltration, the formation of healthy granulations on
the ulcerated surfaces, the disappearance of the papillary excrescences,
the contraction and gradual cicatrization of the ulcers, and an improve-
ment in the subjective condition of the patients.
THE JSTEW YORK MEDICAL JOURNAL, November 21, 188 5.
#rifjuml Commumattiotxs.
MEMBRANOUS DYSMENORRHEA *
By ALEXANDER J. C. SKENE, M. D., Bkooklyn,
PROFESSOR OF THE MEDICAL AND SURGICAL DISEASES OF WOMEN IN THE
LONG ISLAND COLLEGE HOSPITAL.
Membranous dysmenorrhea is an affection which, al-
though rather rare, commands very urgently the attention
of the gynaecologist, because of the dreadful suffering which
it u'ives rise to, and the obstinacy with which it has hereto-
fore resisted treatment. There is a marked uniformity
about this disease. In its pathology and clinical history it
varies but little in different cases. A number of affections
resemble this one to a limited extent, but it stands out wTell
denned, and is easily detected by the experienced diagnos-
tician.
Membranous dysmenorrhoea is an exfoliation in mass of
the mucous membrane of the cavity of the body of the uterus
at the menstrual period. Microscopically, the mass presents
all the histological elements of the true mucous membrane
of the uterus, including the utricular glands, unchanged by
any new or abnormal elements. When it is expelled entire,
it represents a complete cast of the cavity of the uterus,
and is triangular, with an irregular opening at each of the
angles, the one representing the internal os uteri, and the
other corresponding to the ostia of the Fallopian tubes.
This membrane is rather ragged on the outer surface, but
smooth on the inner, and looks exactly as the lining mem-
brane of the uterus does when in position. The size is
usually about an inch long and less than that in width, and
is generally somewhat larger than the normal proportions
of the cavity of the uterus; but this is not always the case.
In this respect it is apparently like the decidua of preg-
nancy; in fact, in general appearance it closely resembles
the decidua vera, but there is a decided difference in its
microscopic elements, sufficient at least to differentiate.
This similarity of the two membranes has led to their being
called the decidua gravida and the decidua menstrualis,
the former beinff the mucous membrane as seen in abor-
tion at a very early stage of gestation, the other the mem-
brane as thrown off at menstruation in this morbid form.
Comparing the behavior of the mucous membrane in
membranous dysmenorrhoea with its changes in normal men-
struation, the difference is as follows: In normal menstrua-
tion, if we accept the views of Dr. Williams, of London,
the whole mucous membrane undergoes fatty degeneration,
disintegration, and elimination, whereas in membranous
dysmenorrhoea the mucous membrane becomes separated
from the walls of the uterus without being changed or dis-
, integrated; exfoliation and expulsion simply occur. The
way in which the separation of the mucous membrane takes
place is not positively known. It is presumed, however.,
that fatty degeneration in the deeper structures of the
membrane takes place, and thereby it becomes detached
from the uterus. It is possible, also, that the capillary
* Read before the Medical Society of the County of Kings, Septem-
ber 15, 1885.
haemorrhage, instead of occurring on the free surface of
the membrane, takes place in the deeper structures, and in
that way dissects off the membrane. This, however, is hy-
pothetical, and needs confirmation. Sometimes the mem-
brane is expelled in shreds, which suggests that the exfolia-
tion either occurs in spots or sections, or else that the mem-
brane is completely separated from the uterus, but becomes
broken up either during expulsion or in handling it after-
ward. It is much more probable that it is completely ex-
foliated and broken up subsequently than that it is sepa-
rated in circumscribed patches. All these facts lead to the
conclusion that the affection is a perversion of nutrition
and function rather than an organic disease, inflammatory
or otherwise, which gives rise to this peculiar behavior
of the mucous membrane at menstruation. It is clearly
evident that there is nothing pathological in the condition
of the mucous membrane itself, but that the whole morbid
process consists in the separation of the membrane in mass,
in place of disintegration, which is the normal behavior of
the mucous membrane in menstruation. There are other
views regarding the pathology of this affection : one, that
it is the result of gestation, which is arrested at a very early
stage, and the membrane thrown off is really a decidua
vera. That this theory is fallacious will be seen when we
come to discuss the physical signs of this affection.
The idea that it is an inflammatory affection can not be
sustained. No such product or result of inflammation is
found elsewhere in the mucous membrane of the body, nor
is it necessary that inflammation of any part of the uterus
should be present in order to produce membranous dys-
meriorrhcea.
Associated with this membranous dysmenorrhoea we oc-
casionally find inflammatory conditions, but not of the mu-
cous membrane of the cavity of the body. There may be,
and often is, a general hyperemia of the uterus and vagina,
but usually it is not greater than that which is seen in nor-
mal menstruation.
There is occasionally, in cases of long standing, cervical
endometritis, but this does not extend to the body of the
uterus. In fact, I believe that a well-defined endometritis
can not occur at the same time as membranous dysmenor-
rhoea. This affection, then, is certainly sui generis, and is not
the result of inflammation in any form or any stage of the in-
flammatory process ;. neither is it a utero-gestation ending
in abortion at a very early stage of pregnancy, as some have
maintained; neither does the membrane partake of the na-
ture of any of the morbid neoplasms which occur in mucous
membranes elsewhere in the body.
The mucous membrane in this affection is developed in
the natural way after each menstruation, and the gross ap-
pearances and histological composition of this structure
show that it is normal, and differs in no way from the mu-
cous membrane of the uterus up to the time when the men-
strual flow is about to begin. Perhaps then' is, in some
cases, an increase in the quantity of the membrane, but only
to a very limited extent, if at all. In short, the onlv patho-
logical lesion in this affection is in the manner in which the
membrane is thrown off.
562
SKENE: MEMBRANOUS DYSMEN OR HIKE A.
[N. Y. Med. Jopb.,
Symptoms. — This affection occurs in single and married
women — about as often in one class as the other, perhaps.
It also occurs in those who have borne children, but in most
of the cases that I have seen in married women the patients
have been sterile. The recurrence of the menstruation is
generally regular ; sometimes it is delayed, and sometimes
there is a sense of pelvic discomfort before the menstrual
flow, but not always. The chief symptom is the pain which
comes on usually during the first day, sometimes later, and
increases in severity and is somewhat intermittent in char-
acter until the membrane is expelled, when it rather abrupt-
ly subsides.
The flow sometimes is scanty previous to the expulsion
of the membrane, and after that it is generally quite free ;
at times abnormally so, and occasionally small clots are
passed.
Sometimes there is a leucorrhoeal discharge succeeding
the menstrual flow, the discharge being occasionally tinged
■with blood. In other cases the menstrual flow subsides
after the expulsion of the membrane, and no leucorrhcea of
any account occurs afterward.
There is really nothing in the clinical history of this
affection by which it can be positively distinguished from
dysmenorrhoea due to other causes. Hence the diagnosis
must always depend upon the physical signs.
Physical Signs. — In order to make a diagnosis, it is
absolutely necessary that the membrane expelled should be
preserved and examined. The gross appearances of the
specimen are usually all that is necessary to satisfy the diag-
nostician regarding the nature of the affection, but in cases
where there is a doubt the microscope must be called in to
aid in the diagnosis.
The morbid materials expelled from the uterus which
simulate the membrane produced in this affection are the
decidua expelled in abortion in the earliest stages of preg-
nancy ; the masses of fibrin which have formed in the
uterus in menorrhagia ; very dense masses of secretion from
the cervix ; and the membranous-looking shreds expelled
from the cervix and vagina after astringent or caustic appli-
cations.
The decidua in early abortion is most difficult to dis-
tinguish from the menstrual membrane. In the early abor-
tion the membrane expelled is usually larger and more
ovoid or round, and not so markedly triangular as the de-
cidua of menstruation, and is also thicker, and usually is
accompanied with villi of the chorion. If there is still a
doubt, the microscope reveals that the menstrual membrane
shows only small cells, while those of the decidua-vera mem-
brane are so great as to be easily distinguished. There is a
decided microscopic difference in the epithelium, the tubes,
and the inter-glandular tissue. This difference between the
two membranes is not only in the decidua of early abortion,
but also in the decidua of extra-uterine pregnancy. In
being thus able to distinguish between the decidua of preg-
nancy and the membrane of menstruation, the only great
difficulty in the diagnosis is overcome.
The shreds of fibrin expelled from the uterus sometimes
look membranous in form, but have none of the structure of
the mucous membrane, and hence can be detected on cur-
sory examination. The same may be said of the masses of
unusually dense secretion of the cervix. The membranous
shreds that come from the cervix and the vagina as the
result of astringent and caustic applications resemble at
first sight the menstrual membrane. The most perfect of
these exfoliations from the vagina I have seen after the use
of the persulphate of iron ; these specimens, however, are
much thinner and differ entirely in structure, being made
up mostly of epithelium, and therefore need not be mis-
taken for the menstrual membrane.
With due attention to the membrane expelled, the diag-
nosis can be made with great certainty. ■
Ca usation. — Discarding the current views regarding
membranous dysmenorrhoea — that is, that it is due to in-
flammation, or else the result of gestation — one is left with-
out any very rational views to offer regarding the causation
of this disease. While it is not, perhaps, the part of wis-
dom to discredit the accepted views on any question in
medicine until one has something more reliable to offer,
still, if the causes assigned can be readily shown to be in-
correct, it is infinitely better and safer to be entirely in
ignorance of the causes of things than to attribute them to
the wrong causes. Fortunately, however, while I find my-
self at variance with most of the recent authorities regard-
ing the cause of this affection, I am in perfect harmony
with the views of Dr. Oldham, who was the first to discover
dysmenorrhoea membranacea.
Dr. Oldham distinctly pointed out the characteristics o
this affection and stated that the membrane was formed
under the ovarian stimulus, and I am fully satisfied that h
was not only the discoverer of the disease, but also con-
ceived the true idea regarding the cause of it — viz., some
undue or abnormal ovarian influence or sexual excitation.
In other words, it would appear to be some derangement o
innervation and nutrition.
Taking this view of the causation, I expect to find my-
self in harmony with the neurologists at least. This class
of specialists manifest a willingness to trace many diseases
originally to some derangement of the nervous system, whe~
they find anything like good reasons for so doing. Hence,
I expect their support in choosing, as I do, to believe that
the starting-point in the pathology of this affection must b
some derangement of innervation produced by disease o
some associated organs like the ovaries. We might find con-
firmation of this view regarding the cause of membranous
dysmenorrhoea in studying the agencies which give rise to
other morbid states of the uterus, like the fibroid growth
for example, which in its anatomical elements does not differ
especially from the tissues of the uterus from which it
springs; and, if we could find the cause of this deviation
from healthy nutrition, it might be applicable to the disease
under discussion. But, unfortunately, the causes of fibroid
tumors given in our literature are unsatisfactory and by no
means well sustained.
From the fact that uterine fibroids are more common in
sterile women than in others, it would appear that sterility
predisposes to their development, and perhaps no better ex-
planation of the cause of these growths has ever been given
than that of my somewhat humorous friend, who said that
Nov. 21, 18*5.]
SKENE: MEMBRANOUS DYSMENORRHEA.
563
" the uterus, being prepared for normal work and not finding-
it to do, took up the development of fibroids as a sort of
outlet to its formative powers." May it not, then, be that a
well-defined predisposition to reproduction, uncalled for by
gestation, excites this morbid action on the part of the
uterus which leads to this abnormal exfoliation of its mucous
membrane ? This view might at least be entertained, be-
cause in other cases, when we are unable to detect the cause
of a disease in something that is tangible, we usually attrib-
ute it to deranged innervation and consequent malnutri-
tion. This view of the causation is, to some extent, sus-
tained by the effects of medicines upon the lesions. This
affection has always been recognized as one that is often
difficult to cure, many times incurable, in the hands of the
most competent physicians and surgeons. This possibly
may have been due to misapprehension of the nature and
cause of the disease, and hence fallacious therapeutics,
rather than to the incurable character of the disease.
In favor of this line of thought I may state that the
patients whom I have treated in years past, on the theory
that the cause was inflammatory, have derived little benefit,
while those who were treated for deranged innervation,
malnutrition, and undue ovarian excitation, have made very
much better progress. I am inclined to attribute most
of the trouble to ovarian influence, the condition of the
ovaries being that of an undue nerve excitation and possible
congestion. I have been led to this belief by two facts :
that the majority of the patients that I have seen have been
subjects of a highly nervous organization, and in most of
them there has been tenderness of the ovaries, and pain at
times in them, without there being any evidence of their
having ovaritis.
The rheumatic diathesis is said to favor this affection,
and it is possible that that may be so, although I am unable
to recall any of my patients as being rheumatic ; neither have
I been able to trace this to the tubercular or strumous dia-
thesis, nor to syphilis. It is certain, however, that, if either
of those conditions existed, they would have their influence
in helping to keep up the uterine trouble, and every effort
should be made to relieve them by treatment.
Treatment. — The treatment of this affection is neces-
sarily both palliative and curative. While the patient is
suffering during the expulsion of the membrane, it is very
necessary to relieve the pain as far as possible. This, of
course, can be most promptly done by the use of opium,
which should be avoided if possible, however, because of its
after-effects.
Chloral hydrate answers fairly well in some cases. I
was induced to try this agent by the accounts given of its
effects in relieving the pains of the first stage of labor. I
am not sure that it has any advantages over chloroform,
camphor and belladonna, or conium and Cannabis indica ; in
fact, in the majority of cases, one has an opportunity to try
several agents, and, of course, the patient will decide which
gives most Telief. Indications for general treatment are to
quiet all nervous disturbance and to improve the general
nutrition of the mucous membrane. It so happens that
when the first part is attended to the latter will follow in
due order.
To quiet the nervous irritation and disturbance there is
nothing that equals the bromide of sodium. This should
be given in twenty- or thirty-grain doses three times a day
for ten days or two weeks before the menstrual period.
And, if the pain is not severe enough to require the addi-
tion of some of the remedies already named to relieve pain,
it may be continued throughout the menstrual period and
several days after. Fr<^m this it would appear that the
bromide is to be used continuously ; but one or two weeks
in each month it can be omitted. "When the bromide has
been employed for some time, and it seems desirable to
give it up, conium may be given in moderate doses com-
bined with camphor, if the patient is weak. If there is
any evidence of the rheumatic diathesis, the bromide of
lithium should be given. Next to quieting the nervous sys-
tem, any debility that may exist should be overcome by
nerve tonics. Undue nervous excitation so often goes hand
in hand with nervous depression that in many cases it is
necessary to combine the tonic and sedative treatment. All
the remedies which may be used need not be here men-
tioned. In regard to the modification of nutrition, it need
only be said here that any accompanying derangements of
the digestive organs that may be found should receive care-
ful attention ; but this hardly need be mentioned in this
connection.
My rule of treatment has been, after subduing all nerv-
ous disturbances, to put the patient upon the iodide of
sodium in case she is in fair strength and inclined to
flesh. If there is anaemia, I prefer the iodide of iron. If
these did not accomplish the object, I have employed mer-
cury, giving it in small doses, never continued long enough
to produce salivation, carefully watching to avoid this. In
cases of anaemia, where I have feared the debilitating effect
of this alterative, I have given the bichloride of mercury
with iron. After keeping them upon this treatment until I
could see some evidence of its effects, I have then put them
upon iodine and arsenic.
In regard to local treatment, I have been entirely guided
by the views of pathology expressed above, and have there-
fore employed alteratives and sedatives almost exclusively.
Of these I have found iodoform most effectual. I have also
used iodine and mercury with advantage. In cases where I
have found any complications I have carefully attended to
them, restoring displacements and correcting flexions, and
so on. When the canal of the cervix has been at all con-
stricted I have enlarged it by incision and dilatation.
When the congestion which occurs at the menstrual
period does not subside in a few days, I have employed the
warm-water douche. After this, I have applied to. the
cavity of the uterus small bougies of cocoa-butter with as
much iodoform as it would take up. Three or four grains
of iodoform mixed with vaseline that has been liquefied by
heat, and introduced through the pipette, is perhaps the
best method of applying it. These have been introduced
once a week or once every five days. When there has
been much tenderness, and the use of the pencils has caused
pain, I formerly used aconite and opium and iodine; this 1
have introduced into the cavity of the uterus. I am now
trying cocaine to subdue the tenderness as a preparatory
564
SKENE: MEMBRANOUS D YtiMEN ORRIHEA .
[N. Y. Mki>. Joce.,
means to the use of the iodoform. But so far this new
remedy lias not heen a perfect success.
In cases where this lias failed and the uterus was not
especially sensitive to intra-uterine medication, I have in-
stilled into the uterine cavity a few drops of a fiye-per-cenfc
solution of carbolic acid, making one application a few days
after the menstrual flow and not repeating it until the next
period. In the interval I have usgd the iodoform. I hare
also used the fluid extract of conium and Hydrastis canaden-
sis ; but this I have found gives more pain than any of the
other applications that I have used; and so of late I have
used an infusion of the hydrastis alone, which appears to
answer as well and gives less pain.
Case I. — Memhranous Dysmenorrhea in a Married Lady
who was never Pregnant. — This patient was forty-one years of
age, of good constitution, and had been married eight years.
She began to menstruate at thirteen, and continued to do so
regularly and normally until she was twenty-one ; then she be-
gan to have occasional pain, about the menstrual period, in the
region of the ovaries. About a year after this she began to
have severe uterine pains during the menses, and states that she
occasionally passed masses that looked like membrane from the
uterus; they were small, however, and did not occur at each
period.
After her marriage the pain at the menstrual periods became
worse, and almost every month she passed a membranous cast
of the uterus. The usual history of each menstruation is that
the flow begins not very free, and, after continuing for about
five hours, the pain becomes very intense and lasts from three
to eight hours, when she expels the membrane and the pain
subsides, the flow continuing for a day or a day and a half after
the membrane has been expelled.
The flow, taken altogether, is not profuse, and only lasts
from two to two and a half days, while formerly — that is, be-
fore her dysmenorrhea began — it used to continue from four to
Ave days. When first seen, her general health was good, but
she was rather hysterical and nervous, and was somewhat de-
pressed and disappointed because she had not had children.
She described her suffering at her menstrual periods as
something unbearable, although it did not last more than a few
hours at a time. She was first examined midway between the
menstrual yjeriods. The uterus was then found to be normal in
size and in good position. The internal os was rather sensitive
and appeared to be slightly contracted ; there was also an ex-
tended Nabothian gland in the middle third of the cervical
canal, but the uterus presented a normal appearance in every
other respect. There was no congestion ; in fact, at this time
the mucous membrane appeared rather anaemic.
The diagnosis was left an open question until the next men-
strual period, when I obtained the membrane expelled and had
it examined by my friend, Professor Frank Ferguson. His re-
port stated that the specimen was uterine mucous membrane
unchanged in its histological composition. This settled the
question of diagnosis.
Careful inquiry elicited the fact that she had never been
pregnant, so far as I could rely upon her testimony, which I be-
lieve to be accurate because of her great desire to have children.
1 also learned that on several occasions she had lived apart from
her husband, who was of necessity absent on business for sev-
eral months at a time, and that she suffered just the same, and
at each month there was an expulsion of membrane, showing
conclusively that there was no possibility of mistaking this affec-
tion for pregnancy and abortion.
The treatment consisted, first, in placing her upon the follow-
ing mixture: Half a grain of the bichloride of mercury, one
drachm of the solution of the chloride of arsenic, three drachms
of the tincture of iron in a three-ounce mixture of syrup and
water. A teaspoonful of this was given, well diluted, after each
meal. At the same time the internal os was incised superficially
in three places, dividing equally the circumference of the canal
and the distended Nabothian follicle was punctured and evacu-
ated.
A week after this a sound was introduced of full size, and
there was less tenderness; the tincture of iodine was then ap-
plied from just within the internal os downward. At the next
menstrual period she had less pain, but it lasted just as long, and
she passed a membrane unchanged, except it did not appear so
thick as formerly.
From this onward the local treatment consisted in passing
a full sized sound just beyond the internal os right after the men-
strual period, and again in two weeks, and in nearly every six
days about two grains of iodoform mixed with vaseline was
passed into the cavity of the uterus, well up toward the fundus.
This local treatment was continued without interruption for
three months, and the first prescription, after it had been taken
for two weeks, was followed by the iodide of iron, a grain and
a half three times a day.
After the second month, and at her third menstrual period
from the time that treatment began, she had no pain and passed
no membrane. At the next period she passed several shreds,
but nothing like a complete cast of the uterus.
The constitutional treatment, that is, alternating between the
first prescription of mercury and arsenic and the iodide of iron,
giving the first one for two weeks, and then the other, was con-
tinued for two months longer. The application of the iodoform
was continued for one month longer, once every week, and once
after her menstruation, at the end of the fourth month of the
treatment. Since that time she has bad no further trouble; her
menses are regular, lasting about three days and entirely with-
out pain or any discharge of membrane.
That was her record at least one year after she gave up treat-
ment, since which time 1 have not heard from her.
Case II. — Memhranous Dysmenorrhea occurring after Treat-
ment for Anteflexion and One Miscarriage. — A lady of very high
culture and over-refinement, of a well-marked nervous tempera-'
ment, but otherwise of good constitution, came under my obser-
vation when twenty-eight years of age ; she had then been mar-
ried a year and a half. She menstruated first at fourteen years,
and continued to do so regularly, but with pain from the very
beginning. The pain usually began a day or so before the flow
and gradually diminished after. Her suffering at each perio''
gradually increased until her marriage, when it became more
severe. This, and the fact that she remained sterile, induced
her to seek advice. I found her suffering from anteflexion of the
body of the uterus and cervical endometritis ; there was also
tenderness of the left ovary on pressure. She was treated for
the flexion and completely recovered. The dysmenorrhcea was
entirely relieved and she became pregnant. During her preg-
nancy she suffered very much from morning sickness, and at the
end of the third month began to show some signs of septicaemia;
she then miscarried, and the ovum was found to be macerated,
and probably had been dead in utero for two weeks. She recov-
ered from this and was quite well for about a year, when her
dysmenorrhcea returned ; she then returned to be treated for
what she supposed to be a recurrence of her former trouble, but
I found no evidence of the former flexion. But, on inquiry, I
found that she passed at each period a membranous cast of the
uterus. The patient thought little of this, because, in former
years while suffering from the dysmenorrhcea caused by flex-
ion, she occasionally passed small clots which looked some-
Nov. 21, 1885.]
JEWETT: NOTES ON HOSPITAL OBSTETRICS.
565
what membranous in character, but no doubt were simply
blood-clots.
She was placed upon treatment similar to that employed in
the first case reported, except that there was no necessity for
enlarging the internal os as in the former case, the only differ-
ence in the local treatment being that I used iodine in place of
iodoform during the last two months of the treatment; and
once, immediately after her menstrual period, I applied a mild
solution of carbolic acid to the uterine cavity.
She did not again pass any membrane after the third month of
treatment, and her pain from menstruation entirely disappeared.
She was dismissed at the end of four months, and two months
afterward reported that she was pre'gnant. Three months after
that time she was examined and found to be so, and was pro-
gressing well. Since that time I have not seen her, but heard
that she gave birth to a healthy child.
Case III. — Membranous Dysmenorrhea treated by Dr. For-
dyce Barker, of Neic York; Complete Recovery . — I give the his-
tory of the following case for two reasons : First, to show that
iodoform was employed in the local treatment, and that the pa-
tient's recovery was complete ; and also to take the opportunity
of stating that I believe that Dr. Barker was the first to employ
this agent.
The history is not altogether complete, because I obtained it
from the patient herself, who was unable to tell all that was
done for her; but I know positively that she suffered from dys-
menorrhcea, and that she entirely recovered under the care of
Dr. Barker, and has remained well for a number of years.
This was an educated lady of a well-marked nervous temper-
ament ; she began to menstruate at thirteen, and continued to
do so normally until she was twenty-six years of age. At that
time she was said to have had an acute attack of ovaritis, and
after recovering from that she had dysmenorrhoea.
The character of the pain at her menstrual periods then ap-
peared to be ovarian. After suffering in this manner for about
four or five years she noticed the expulsion of membranous
casts of the uterus at the menstrual periods. During this time
and for a year afterward she was regularly treated by her family
physician, but without relief. She then consulted Dr. Barker
for her general ill-health, but did not call his attention to her
derangement of the menstrual function. She improved in her
general condition under his care, but found no relief from the
membranous menstruation. She consulted him again and called
his attention to the uterine trouble, and he immediately placed
her under treatment.
The constitutional remedies employed I do not know, but
the local treatment consisted in dilatation of the cervical canal
and the application of iodoform to the uterine cavity.
She continued to pass membrane for several months; then
the trouble ceased and has not returned. She now menstruates
regularly and naturally, and has done so for over two years.
Several other cases might be added, some showing fail-
ure of treatment, and others where the patients were really
made worse by being treated for inflammation of the uterus
which was supposed to be the cause of the trouble, but un-
doubtedly was not. Other cases might be given, also, in
which recovery took place, and after several months or years
the trouble returned, but they would add nothing to the
views already given regarding the pathology and treatment
of this affection.
The Charcow Ophthalmological Clinic, according to the " St. Peters-
burger medicinische Wochenschrift," has lately received a legacy of
12,000 roubles, the interest of which is to be applied to the mainte-
nance of additional free beds.
NOTES ON HOSPITAL OBSTETRICS*
By CHARLES JEWETT, A. M., M. D., Brooklyn,
PROFESSOR OF OBSTETRICS IN THE LONG ISLAND COLLEGE HOSPITAL.
One hundred consecutive confinements at the Long
Island College Hospital furnish the material for the greater
part of these rambling observations. Seven cases of abortion,
however, scattered through the same period, are of some
interest, and, before entering upon the study of the term
labors, I will state in brief detail the treatment pursued in
abortions. All fell in the second or third month. All were
treated by immediate removal of the secundines. Of the
seven patients, three had high temperatures on admission,
with putrid secundines. Another was extremely anaemic
from hemorrhage, and her condition was further compli-
cated with delirium tremens. In all the uterus was im-
mediately evacuated substantially as follows:
The patient was placed in the latero-prone position and
the cervix exposed by means of Sims's speculum, and stead-
ied with a volsella. First the vagina and then the uterus
were thoroughly cleansed with a douche of the bichloride
solution, 1 to 1,000. The secundines, if separated, were then
removed with a uterine dressing forceps, and the cavity
was curetted with the small dull curette. If the ovum was
still partially adherent, it was first detached with the curette.
The cavity of the uterus was finally irrigated a second time
with bichloride solution and a soft iodoform pencil depos-
ited therein. In the febrile cases the temperature promptly
declined, and all pursued a favorable course, the patients
being discharged in from five to ten days.
Sims's speculum has few more important uses than in
the treatment of abortion. The detached ovum is extracted
by the above-described method with almost as much ease
as it could be picked up from the floor. The facility of
removal is in striking contrast with the painful and awk-
ward digital method of extraction.
The immediate evacuation of the uterus is demanded in
the event of sepsis or much haemorrhage. Even in the ab-
sence of these conditions I have generally preferred the
immediate operation, including separation with the curette,
when the ovum had clearly become a foreign body. I have
seen no evil results from this course, while delay may ex-
pose the patient to a sepsis which later evacuation is power-
less to arrest, to say nothing of the evils of haemorrhage.
The ordinary small dull curette answers the purpose, and
has the advantage that but little dilatation is required. I
have rarely used any other. The important point, when
interference is practiced, is to operate if possible while the
tissues of the ovum are still fresh, and to leave the uterus
completely empty and aseptic. The radical treatment of
abortion and the use of the Sims speculum were advocated
several years ago by Dr. Skene.
The one hundred term-confinements were conducted in
surroundings involving more or less septic exposure. The
obstetric wards were in the oldest portion of the building
and in immediate proximity with the surgical wards of the
hospital. The obstetric interne was also on general medi-
* Read before the Medical Society of the County of Kings, Septem-
ber 15, 1885.
566
JEWETT: NOTES ON HOSPITAL OBSTETRICS.
[N. Y. Med. Jock.,
cal duty, and a certain number of students and nurses were
admitted to witness the labors. Despite the unfavorable
circumstances, no epidemic of fever prevailed. No two con-
secutive confinements were followed with serious fever, and
the total number of cases that could be classed as uncom-
plicated puerperal septicaemia were only seven. In this
number there were three deaths.
In several cases circumstances pointed clearly to the
belief that the poison was conveyed by the attendants on
the labor, and not by the atmosphere. Atmospheric infec-
tion, I am disposed to think, is the exception and not the
rule. In the majority of cases puerperal sepsis must be
attributed to the pbysician or nurse in attendance during
the labor. Cleanly surroundings, however, are of course
indispensable to the cleanly conduct of the labor.
Our antiseptic practices of the last year have been some-
what simplified. They consist mainly of measures ad-
dressed to the scrupulous cleanliness of everything that is
brought in contact or proximity with the passages, particu-
larly during labor. Antiseptics are often indispensable to
this end, especially to the aseptic cleanliness of hands and
instruments. Vaginal injections are not used in puerperal
patients for prophylactic purposes, except when specially
indicated. The usual lochial guard, however, is kept wet
with the bichloride solution for the purpose of promoting
an aseptic condition of the external genitals.
The lying-in department has within a few weeks been
transferred to new quarters in the wing recently erected.
It is wholly cut off from direct communication with other
portions of the hospital buildings. It is accessible there-
from only through the open air. The wards are ranged on
either side of a central corridor, and are provided with am-
ple ventilation. In the convalescent wards and waiting-
room pure air is admitted by a double system of flues, one
for heated and one for cold air. The foul air is removed
bjT flues communicating with a central upcast shaft, in which
a strong draft is maintained the year round by means of a
steam stack. Transom-windows add still further to the
ventilating appliances, and all the incoming currents are
regulated with reference to proper distribution so as to
break up the entire volume of air in the room. A room for
the isolation of fever patients is located in a remote portion
of the wing.
All the wards have been constructed with a view to
make them proof against the accumulation of hospital mi-
asm. The walls and ceilings are finished with Keen's
cement, and the floors are of concrete, painted. The wood-
work is of the plainest kind, and the grain well filled.
Since the walls and floors are like stone, in addition to the
usual means of disinfection the wards may be flushed with
a hose. A steam cylinder, which can be charged from the
engine-boiler, is provided for disinfecting the bedding by
high temperature.
Passing now to the analysis of the term confinements,
the nationalities of the mothers were chiefly Irish, Swedish,
and Americans of foreign extraction. The number of sm-
gle women was forty. Fifty-six women were confined for
the first time, forty-four were multiparas. The youngest
mother was seventeen years old. Of aged primiparae there
were six of ages ranging from twenty-nine to thirty-eight.
All were delivered without artificial interference, and the
average duration of their labors was a little below the
average in the younger primiparae. These cases prove
only that dystocia does not always befall this class of par-
turients.
An unusually large proportion of maternal abnormities
was encountered. There was one case of simple flattened
pelvis, one of funnel-shaped or male pelvis, one kyphotic
pelvis, and two cases of cancer of the cervix.
As there was one twin birth, one hundred and one chil-
dren were born. Of this number, ninety-three presented
by the vertex. There were four breech cases, two cross
births, one head and hand, one head, hand, and funis pres-
entation.
The proportion of vertex presentations conforms nearly
to the usual average, which is generally stated at about
ninety-six per cent. Only fourteen per cent, of the vertex
cases are recorded as occipito-posterior positions. Since
nearly one half of the patients, however, were more or less
advanced in labor on admission, the records of position are
inexact.
Seventy-seven labors were accomplished solely by the
natural powers. There were thirteen forceps deliveries,
three manual extractions in breech births, three cases of
podalic version, one delivery with the blunt hook (a breech
case, the child dead), one by craniotomy (child dead, de-
formed pelvis), one Cesarean section, one laparo-elytrotomy.
(The laparotomies will be found elsewhere reported.) The
average weight of the children in the forceps cases was
nearlv eight pounds. Thus the child was an element in the
dystocia.
In forceps operations the aim has been to deliver with
a minimum amount of force. Probably in none of the
above-mentioned cases did the traction force exceed fifty
pounds. To deliver with the least possible force, three
things are necessary :
1. Time. It is often possible to coax the head along
very slowly with moderate traction when a rapid delivery
would involve a great expenditure of strength and much
violence to the mother. It is a law of mechanics that the
resistance which a moving body meets with increases as the
square of the velocity. This law is not wholly inapplicable
in the forceps operation.
2. The previous correction, when possible, of malposi-
tions of the head. This is not always possible.
3. Axis traction — in other words, the application of the
force in the axis of the passages. Misdirection not only
wastes force, but, worse than this, the waste force is ex-
pended in doing harm. The axis-traction forceps of Tar-
nier and its modifications offer great advantage in many
cases of high operation. In these instruments the extract-
ing force is applied in the axis of the forceps blades, and
the axis of the blades lies constantly parallel with the axis
of the passages as the head descends. The ordinary for-
ceps should do the same thing. This can not be accom-
plished by mere traction upon the handles, certainly not
with forceps having a marked pelvic curve. It may be
done by conjoining with traction, applied at the handles by
Nov. 21, 1885.|
one hand, a downward pressure with the other hand upon
the shanks near the lock.
The operator is often in doubt as to the precise direction
of the pelvic axis. I am not sure to whom I am indebted for
the following useful hints for solving this difficulty and guid-
ing the lincft)f traction. The symphysis pubis is substantially
parallel with the axis of the brim. The direction of the sym-
physis may be readily determined by laying the finger along
its internal surface or by placing the finger-tips externally over
the extremities of the symphysis. This affords a guide to
the line of traction, which deviates but little from the axis
of the inlet till the occipital pole approaches the pelvic floor.
As the head glides along on the floor of the pelvis the for-
ceps handles should sweep forward rapidly enough to make
the anterior margins of the blades hug the ischio-pubic rami
as closely as possible without crushing the intervening soft
parts. These rules serve for general guidance in the use of
forceps, but may of course require modification in individu-
al cases.
In connection with this subject I submit a forceps
which has been made for me by the Messrs. Tiemann & Co.
It is designed to meet the requirements of modern obstet-
rics in the matter of cleanliness. The only important new
feature is the construction of the handles. The handles are
of hard rubber, smoothly polished, and they wholly envelop
the metal. As the rubber is vulcanized upon the metal,
there are no crevices for the lodgment of filth. With the
exception of the handles, the general model of the instru-
ment is similar to the Elliot forceps, but the shanks are
stronger and the lock is a half Smellie.
In the seven breech extractions none of the children
were lost except one, which was dead for two or three days
before the admission of the mother. The method followed in
breech deliveries is as follows: A forceps is always within
reach of the hand. An assistant stands ready to apply
pressure over the fundus at the critical moment — the deliv-
ery of the head. Anassthetics are generally withheld to
secure the full use of the expelling forces of the mother.
In order to the full dilatation of the passages preparatory
to the delivery of the after-coming head, the pelvic extremi-
ty of the foetal ovoid is left intact — in other words, the ex-
tremities are, if practicable, allowed to remain flexed upon
the abdomen, and the descent of the breech is not usually
hastened by traction. Another reason for avoiding traction
is the fact that the head and arms are liable to become ex-
tended if the trunk is dragged down. When traction be-
comes necessary in case of delayed or impacted breech, the
attempt is made to maintain the flexion of the head by
means of external pressure applied over the abdomen by
the assistant. In the expulsion of the trunk much depends
on the prompt delivery of the arms. If manual extraction
<>i the after-coming head is not readily accomplished with
moderate force, the trunk of the child is carried up over
567
the abdomen of the mother and the forceps applied to the
head. Great reliance is placed on the forceps in difficult
delivery of the after-coming head. The application is easy,
and, once applied, failure is practically impossible where a
living child is possible by any method of extraction. On
the other hand, manual methods in difficult cases frequently
fail, and, when successful, are liable to inflict fatal injury
upon the spinal cord.
Episiotomy was done in one case. In rare instances
this procedure is believed to be good practice in rigid peri-
naeum where extensive rupture of the perineal muscles
would otherwise be inevitable. At the moment when the
equator of the head is about to escape from the vagina, a
narrow-bladed, blunt-pointed knife is laid flatwise between
the head and the cord-like constricting ring just within the
vaginal outlet. The incisions are made an inch or more
from the median line, and should not much exceed half an
inch in length and an eighth to a quarter of an inch in
depth. I prefer to make the incisions during a pain, since
they can be more readily managed while the ring is tense.
The compress and T-bandage suggested by Dr. Skene
for support of the pelvic floor after labor, in certain perineal
injuries, will be found useful after episiotomy. It should
be understood that this operation is not advisable except
where other measures are inadequate.
With the use of Crede's method the placenta was in
the majority of cases expelled in from fifteen to twenty
minutes after the birth of the child. The longest placental
stage recorded was forty-five minutes. In delayed third
stage, injection of the placenta through the cord has been
found a useful measure, though by no means invariably
successful. This practice is not new, having been advo-
cated by various writers since the early part of the present
century. I use a small hard-rubber cannula attached to the
syringe, though a common quill toothpick will answer the
purpose. Cold water is injected through the umbilical
vein, care being used to avoid injection of air. The effect
of the cold water, when successful, is to provoke a vigorous
contraction, usually attended with prompt expulsion of the
placenta. Manual extraction in retained placenta is avoided
if possible, though little danger is to be apprehended if the
hand is aseptic.
Lacerations at the vaginal orifice of some grade occurred
in thirty-six cases. This number includes wounds of every
degree beyond mere nicking of the hymeneal orifice or of the
fourchette that could be detected on critical examination.
All but three occurred in first labors. Eleven of this num-
ber were not of sufficient extent to involve the muscular
structures of the perinseum ; none extended through the
sphincter ani. The proportion of perineal injuries may
seem large, yet I am disposed to think it is little larger than
would be found in general practice were the same oppor-
tunity afforded for careful examination. The number was
no doubt increased by the fact that in a certain proportion
of emergency cases brought on the ambulance the head was
rapidly expelled before aid could be rendered. The meth-
ods practiced for the protection of the perinamm are chiefly
preliminary dilatation, delay, and delivery of the head l>v
its smallest circumference.
JEWETT: NOTES ON HOSPITAL OBSTETRICS.
568
JEWETT: NOTES ON HOSPITAL OBSTETRICS.
[N. Y. Med. JocbJ
All except the most superficial rents were immediately
closed with sutures. The single suture of Alloway was
tried in two or three cases, but was unsatisfactory and was
abandoned. No method can meet the indications which
does not hold the sundered muscular structures in apposi-
tion throughout.
One perineal laceration extending into the sphincter ani
united without sutures, forming a thick and firm muscular
body. This patient was delivered fourteen hours before
admission. On examination after she entered the hospital,
the torn surfaces of the perinanira were found cemented
together, and therefore no sutures were applied. The case
is of interest because very exceptional, and is not referred to
as affording a guide for the management of perineal rupt-
ures.
Of fifteen multipara} submitted to critical examination
before labor, old perineal injuries sufficient to impair the
function of the pelvic floor in some degree were found in
nine. In four the damage to the muscular structures was
out of proportion to the apparent injury, the mucous mem-
brane and skin having remained nearly or cpiite intact, while
the muscles had been more or less extensively sundered.
In twenty-eight primiparae in whom the condition of
the cervix at the date of discharge was recorded, lacerations
were found in eighteen. All but seven of this number were
of slight extent. These examinations, however, were made
about ten days after labor, and probably all but the deepest
fissures became insignificant by the time involution was
complete.
In the one hundred mothers there were six deaths.
One woman died of peritonitis and exhaustion three or four
hours after delivery. She had been brought in after four
days' labor with epithelioma of the cervix and a laceration
opening into Douglas's pouch. The child was dead, and
the breech, which presented, was fixed in the grip of the
unyielding cervix. Another patient with cancer of the cer-
vix died of peritonitis after Csesarean section. This case
has been elsewhere reported.
One death occurred from prolonged labor with deformed
pelvis. This woman was admitted in a state of collapse,
with a pulse of 180, after being about four days in labor,
the head arrested at the pelvic outlet. The child was dead
and putrid. Delivery was accomplished by craniotomy.
The thorax and abdomen required to be punctured before
the trunk could be delivered, owing to distension from
putrefactive gases. The right vaginal wall was the seat of
an extensive slough from long-continued pressure of the
foetal head. The woman died soon after delivery. The
remaining three deaths were due to puerperal fever.
In fifty-six patients the temperature did not reach
100° during the post-partum week. There were four with
moderate septic fever who recovered. The recoveries were
due in large measure to antiseptic irrigation of the passages,
a sharp decline of the temperature invariably following the
douche, while in the three fatal cases of fever the douche
made no impression on the temperature.
The remaining abnormal temperatures were due in some
cases to pre-existing disease, as rheumatism, phthisis, etc. ;
in others to malarial poisoning, to mastitis ; in several in-
stances to emotional disturbance, and doubtless in a number
of cases to slight transient absorption of decomposing
lochia.
A case of labor in a diabetic subject is worthy of special
mention. The woman was single and pregnant for the first
time. She was delivered by the high forceps operation after
twenty-six hours of ineffectual labor, the child weighing
eight pounds and eight ounces. Chloroform was badly
borne. She went into partial collapse after delivery, and
was rallied with difficulty.
This patient had more or less fever for two weeks after
labor, the temperature several times mounting to 103°. A
partial laceration of the perinaeum, which had been closed
with sutures, failed of union, sloughs occurring on both
sides of the rent. She had phlebitis of the superficial veins
of the lower extremities. The seat of the punctures on the
thigh, where fluid extract of ergot and dilute ammonia-water
had been injected h vpodermically, formed phlegmons, in
two or three of which sloughs separated, exposing the mus-
cular structures.
Dr. Dickinson, suspecting diabetes from the appearance
of the wounds, confirmed the diagnosis on examining the
urine for sugar. This case affords a good example of the
dangers to which a diabetic woman is exposed in parturition.
Sugar occurs physiologically in the urine of most women
during the latter weeks of pregnancy and during lactation.
Blot found it in half the cases examined during pregnancy.
Dr. Angus Macdonald ("Ed. Med. Journal," August, 1881)
examined the urine for sugar in thirty-four puerperal women
and found from one to eight per cent, in all. This physio-
logical glycosuria is intimately associated with lactation.
De Sinety showed that the amount of sugar in the urine
of puerperal women could be increased at will by abruptly
suppressing the flow of milk. Barnes says the sugar disap-
pears from the urine when the production and yield of milk
are evenly balanced.
Diabetes as a complication of pregnancy and labor is
rarely mentioned in the text-books. Dr. Matthews Duncan
("Obs. Trans.," London, 1882, p. 256), in a paper cited by
Plavfair, relates several cases. A large proportion of the
children die before birth. Hydramnios is more frequent
than in other gravida?. But the principal dangers to this
class of parturients are those of collapse after labor and
their inability to bear well the traumatism of parturition.
Of the children, all but one were single births. Of the
one hundred and one children, forty-five were females and
fifty-six males. The relation of the foetal pulse-rate to the
sex was by no means constant, but in a large proportion of
cases where the foetal pulse before birth was much above
140, the child was a girl or a feeble male; where much
below 140, the sex was generally male.
Ninety-four children were believed to be strictly full-
time births. Of these, the average weight was seven pounds
and one third, excluding the twins. The largest child
weighed eleven pounds. The average length of the full-
time children was a fraction less than nineteen inches. The
length of the new-born child affords a convenient means for
estimating the stage of development. The measurement
may be roughly determined, even in utero, as a ready meth-
Nov. 21, 1885.|
MEHZBACH: THE GENERAL PATHOLOGY OF FEVER.
569
od of estimating the stage of gestation. The length of the
•foetal ovoid can generally be readily measured. Double
this measurement gives very nearly the total length of the
foetus.
A limited number of observations were made upon the
temperature of the new-born child. The average rectal
temperature in twenty infants at birth was 96-4°. On the
second day the average was 98'5°, on the third 98-7°. The
lowest temperatures occurred in puny and in partially
asphyxiated children. The lowest noted at birth was 94°.
Four children were still-born, all dead before the admis-
sion of the mothers. One died from prolonged labor ob-
structed by cancer of the cervix, one from prolapsus funis,
one from ante-partum haemorrhage, and one child was dead
and putrid from prolonged labor with narrow pelvis.
But one foetal abnormity occurred. This was a case of
atresia ani. The obstruction was a membranous septum
which was punctured and the opening dilated by tearing.
Subsequent dilatation was maintained by the mother's finger
used as a bougie. The child was thriving when it left the
hospital. A small glass speculum was found of great ser-
vice in determining the extent of the occlusion and in
puncturing the membrane without injury to surrounding
structures. The speculum was improvised by cutting off an
inch from the open end of a test-tube and rounding the cut
edges in the flame of a spirit lamp.
A modified Crede's treatment has been for some time in
use for the prevention of ophthalmia of the new-born infant.
A few drops of a five-grain solution of nitrate of silver are
instilled into the eyes of every child immediately after
birth. No cases of ophthalmia have occurred since the
adoption of this practice, while they were not wanting
before.
In conclusion, ray acknowledgments are due the house
staff for intelligent and untiring interest in the clinic, and
to Dr. R. L. Dickinson, clinical assistant to the chair of
obstetrics, for valuable aid in securing accurate observations
and for rare skill and judgment in directing the service.
THE GENERAL PATHOLOGY OF FEVER*
By JOSEPH MERZBACH, M. D., Brooklyn,
GYNECOLOGIST TO THE SOUTHERN HOSPITAL AND DISPENSARY.
Before entering upon the subject of my paper I may
be allowed to make a few remarks on the physiological
aspect and those modifications of temperature which we are
accustomed to consider as normal.
Heat is the result of molecular motion, and temperature
the expression of the velocity of this motion. The three
factors on which the action of the relatively constant tem-
perature of the human body is dependent are : the produc-
tion of heat, the loss of heat, and the regulation of heat.
Lavoisier was the first to pronounce the production of heat
a process of oxidation — viz., a combination of oxygen in
the air with the carbonic acid of the blood. All the later
researches in this direction go to show that the greater part
* Read before the Brooklyn Pathological Society, September 24,
1885.
of the heat produced in the human body is brought about
by this process, and that this process takes place in the tis-
sues themselves and not in the lungs, as was believed by
older physiologists. But where the amount of heat comes
from not accounted for by oxidation has as yet not been
determined.
This production of heat is counterbalanced by the con-
stant loss of heat. Heat is lost by the introduction of air
and food of a lower temperature than that of the body, by the
evaporation of water from the surface of the lungs and skin,
and by conduction and radiation of heat from the skin, as
long as the temperature of the skin is higher than that
of the surrounding atmosphere. Of these three agents, the
skin is by far the most important, giving off eighty per
cent, of the whole amount of heat produced in twenty-four
hours ; the lungs dispose of about eighteen per cent., while
the remaining two per cent, is required for the heating of
food.
This paramount position of the skin among the heat-
losing organs, and its relation to the temperature of the sur-
rounding atmosphere, ought not be lost sight of in the treat-
ment of febrile disorders. I am very much inclined to
ascribe the favorable results of out-door treatment in fevers
more to the lower temperature and greater motion of the
air, by which the skin is enabled to give off steadily quite
a considerable amount of heat, than to the better quality of
the atmosphere, although, as a matter of course, I am not
prepared to deny the beneficial effect of the latter agent.
After having thus briefly touched upon the subject of
production of heat and loss of heat, the question naturally
arises: What is the arrangement by which the organism is
enabled, even under very considerable variations of the sur-
rounding temperature, to almost constantly maintain its own
heat ? There are several contrivances by which this object
is accomplished, the most evident of which is probably the
skin and the regulation taking place by the elasticity of the
cutaneous capillaries. If the surrounding atmosphere is
cold, the vessels contract, the difference between the tem-
perature of the skin and atmosphere is lessened, and, conse-
quently, the loss of heat is diminished. When the skin
comes in contact with warm air, the cutaneous capillaries
expand, the difference between the surrounding and internal
temperature increases, and the loss of heat becomes greater.
It must also be taken into consideration that in the first
case the amount of blood exposed to the cooling influence
of the air, and the action of the perspiratory glands, is less,
while in the latter case it is greater, the supposition being
in both cases that the temperature of the atmosphere is
below that of the body.
By change of clothing the human being contributes
toward regulation from the skin.
Another agent of regulation is the spontaneous increase
or decrease of heat-production by change of food; the in-
fluence of this agent can not be proved for short spaces of
time. In regard to longer periods, we find, as a matter of
tact, that the inhabitants of colder climates not only take a
larger amount of food than those of warmer regions, but
also that they favor such articles of food as are likely to
produce more heat. That the respiratory activity varies in
570
MERZBACH: THE GENERAL
PATHOLOGY OF FEVER.
[N. Y. Med. Joitk.,
different temperatures is generally conceded, while the
share of the nervous system in the regulation of heat is still
subject to much discussion. It is a matter of course that
the nervous system, by its influence on the blood-vessels,
must contribute toward regulating heat ; but whether it has
a more direct action is the question. The direct action un-
doubtedly takes place in muscles and glands ; in these heat
is generated on exciting their nerves, even after circulation
in them is entirely stopped. But for all the other tissues
of the body the influence of the nervous system could not
be proved.
The existence of special caloric centers has not been
experimentally demonstrated. All the experiments neces-
sary for the removal of the nerve-centers so deeply affect
the organism that the resulting changes in temperature may
just as well be ascribed to the influence of the operation as
to the absence of the nerve-centers. And yet there are
clinical facts which, without the admission of such caloric
centers, are difficult, if not impossible, of explanation. I
Lave at present a man under observation who, four months
ago, had an apoplectic stroke. The most annoying symp-
toms which remained therefrom till now are the following:
A defect of vision on one side, slightly diminished memory,
and cold feet. The symptom last mentioned can not be
explained by a lesser degree of mental or muscular activity,
because the man is just as energetic and active as before.
It also can not be traced to a lesser amount of food, because
bis nourishment is of the same quantity and quality as for-
merly. It therefore seems rational to suppose, in this case
at least, that the cerebral injury has involved special caloric
centers.
After thus having called your attention to the three fac-
tors essential to the maintenance of the relatively constant
temperature of the human body, let me briefly review some
of the conditions which normally modify its constancy.
Age produces variations in this way : that the temperature,
which immediately after birth is 99*5° to 100°, falls after
the first bath to 98-6°, to rise again to about 99°. It then
gradually falls one per cent, up to the age of fifty. Be-
tween fifty and sixty it remains constant, to rise again, so
that at the age of eighty the temperature equals that of the
new-born.
Sex has no perceptible influence.
The diurnal deviations are from Q7'2°, at 5 to 6
o'clock, to 98-9° between 5 and 7 o'clock p. m.
The influence of food is not considerable enough to
attract our special attention. It may be said, though, that
the fall of temperature as the result of cold drinks is some-
what more considerable than the rise produced by hot in-
gesta. Alcohol, even in moderate doses, reduces tempera-
ture, probably as the result of a greater loss of heat through
changed circulation.
Muscular exercise may cause a rise of from -5° to nearly
2°. The abnormally high temperature of tetanus is certainly
not due alone to muscular work, but also to the underlying
pathological condition, and possibly to a narrowing of the
capillaries, by which the loss of heat is diminished.
Mental work influences temperature but slightly, at
least in our climate ; in tropical countries a rise of 2° has
been observed. In modification of this statement I must
remark that the president of this society, Dr. B. F. West-
brook, succeeded, by great mental concentration, in pro-
ducing a rise of 2° ; I myself was not able to increase my
temperature by mental work more than 0-4°.
The surrounding atmosphere has no remarkable influ-
ence as long as the mode of living, food, and clothing are
appropriate ; these being defective, very low temperatures
may produce a fall of heat sufficient to cause death.^ Very
high temperatures can be borne to a remarkable degree in
a dry atmosphere. The danger of sunstroke is greater, of
course, in a saturated atmosphere and with muscular exer-
tion.
Normal menstruation and pregnancy do not influence
the bodily heat ; the higher temperature of the pregnant
uterus is partly due to the fetal production of heat, partly
to the great muscular development of the organ. After de-
livery, the temperature rises almost invariably, and we all
know how difficult it is to fix a boundary between normal
and abnormal ; and it will always be necessary for the forma-
tion of a correct judgment not to rely upon the thermome-
ter alone, but to take all the concomitant circumstances into
consideration. The influence of refrigeration on the tem-
perature of the body, in the present state of therapeutics in
fever, requires mentioning. The first effect of cold applica-
tions— and an effect more marked in proportion to the ex-
tent and intensity of the application — is a slight rise of the
axillary with a fall of peripheral and rectal temperature,
while the continuance will change the axillary increase into
a decrease, and will force still lower down the peripheral
and rectal temperature. The difference of behavior between
the axillary temperature and that of other regions has been
explained by Liebermeister through a relation between
heat-production and loss of heat. He holds, and seemingly
proved by calorimetric researches, that the production of
heat increases in proportion to the loss, and that, as long as
the loss of heat does not take on an extent which can not
be antagonized by increased heat-production, the internal
temperature will be higher in proportion to the lowering of
peripheral heat. This explanation was based on experi-
ments which with other observers did not by any means
yield identical results ; and besides that it does not agree
with the fact that the temperature in the rectum, and even
in the vena cava inferior (Ackermann), declines at once as the
result of refrigeration. The axillary rise has so far not
found a satisfactory explanation ; the most plausible theory
is that the only vaso-motor nerves not subject to the irri-
tating influence of refrigeration are those governing the
muscular blood-supply, and that these, instead of producing
contraction, allow their blood-vessels to expand under the
increased blood-pressure ; therefore the temperature of the
muscular tissues which is found in the axilla rises, while the
peripheral and internal temperatures decline. Whichever
theory may be right, there is a general agreement about
the clinical fact (and this is of paramount importance to us)
that the general temperature of the body declines after a
more or less continued application of external cold.
Great reduction of temperature is also brought about
by considerable losses of blood and the injection of gases
Nov. 21, I885.|
MERZBACH: TEE GENERAL PATHOLOGY OF FEVER.
571
into the abdominal cavity. I need not go into the modus
operandi thereof, as the subject of my paper gives me more
interest in the exploration of the causes which produce high
temperature. Elevation of temperature is the only symp-
tom which is common to all fevers, and we may therefore
define fever as a general disturbance of the system, the
pathognomonic sign of which is an increased temperature.
Hence the Latin " febris," from " ferveo," I am warm, and
the Greek " pyrexia," from irvp, irvpos, the fire. All the
other symptoms — as dryness of the skin, increased action of
the heart, change of secretions, chills, nausea, and thirst —
may be absent. On the other hand, headache, pains in the
back, and a feeling of fatigue, which we so commonly find
in fevers, may be present in other conditions of the system
which lack an elevation of temperature. Therefore I think
we are justified in designating the elevation of temperature
as the only sign by which we are always enabled to make
the diagnosis of fever.
The pathogeny of fever has always eminently occupied
the minds of medical men, as may be expected from the
importance of its position among diseases ; and the history
of theories on fevers, like that of other diseases, teaches
"the imperfection of one pathological view for the explana-
tion of all the symptoms of a given disturbance. Ac-
cording to the prevailing theory of the times, fever has
been explained by physical and by chemical processes — by
changes in the vascular system, by derangement of the
nervous system, by increase or decrease of tissue-irrita-
bility," etc.
Even philosophy and religion have been made use of for
the explanation of the morbid phenomena of fever ; thus I
may mention, for the sake of curiosity, that Stahl, accord-
ing to whom all vital processes were controlled by a single
principle — the soul — defined fever as " an almost conscious
motor, secretory, and excretory act for the removal of nox-
ious matters." To discuss all the theories mentioned, to
give all the arguments in favor of and against every one of
them, would lead me too far. I may therefore be allowed
to proceed at once to the modern views on the pathology of
fever.
That there is at the root of every fever something for-
eign to the normal blood is generally accepted ; it may
come from without, as in infectious diseases, or it may be
formed within the organism, as in septic processes. Abe ut
the nature and character of the disturbing element there are
just at present numerous theories. Bacilli, fungi, bacteria,
and micrococci are discovered one day, to be mercilessly
murdered the next. We may safely say that, with very
few exceptions, the microscope thus far has failed to dem-
onstrate the entity and the differential character of the mod-
ern microphytes so as to insure their general acknowledg-
ment. We are therefore compelled to leave this question,
and we now ask in what way does the disturbing element
affect the system ?
Is the blood but the carrier of these little organisms,
which, upon their arrival in the tissues, modify metamorpho-
sis? Or does the presence of these elements cause an inter-
mediate product in the blood which irritates the tissues?
Furthermore, does the disturbing element act on the tissues
directly or by the intervention of the nervous system ? And,
if the nervous system is responsible, is the central nervous
system directly irritated by the foreign element carried to
it by the blood? Or has the disturbance primarily acted
on peripheral nerves, whence the irritation is communicated
to the central nervous system ?
All the attempts to answer these questions have so far
been result! ess, and all the theories whicb take for their
foundation either blood, or tissues, or peripheral nerves, or
the central nervous system, have been refuted, notwith-
standing the able advocates they found. It seems highly
probable, therefore, that all these organs have their share in
the primary causation of fever, and that the greater or lesser
extent to whicb their share in a special case is limited de-
pends on the nature and character of the disturbing element.
In other words, I do believe that every attempt at the patho-
logical generalization of fevers will be futile, and that, for
the explanation of all the symptoms of a given case, it will
be necessary to determine more accurately the special and
differential character of the disturbing cause.
For an explanation of the most prominent phenomena
we must go back to our three great factors in animal heat
— viz., heat-production, loss of heat, and regulation of heat.
That heat-production is increased in fever may be ad-
mitted as generally conceded; also that the process of com-
bustion extends more to nitrogenous than non-nitrogenous
substances. Of course, this factor alone can not be held
responsible for the causation of an increased temperature,
because then we should have elevation of temperature in all
conditions of the system where combustion is increased —
for instance, after meals. That this is not the case was
shown in my remarks on the normal modifications of heat.
Traube's theory, by which he explained the phenomena of
fever by diminished loss of heat, is opposed by the follow-
ing considerations : It has not been proved that the con-
traction of the small arteries precedes the other phenomena
of fever ; it can not, therefore, be asserted that this contrac-
tion maintains a causal relation to the rise of temperature.
Secondly, were the pyrexia due only to the diminished loss
of heat, temperature should under all circumstances fall
when the loss of heat is increased. This does not take
place in acute rheumatism, puerperal, septic, and hectic
fevers.
The theories which place the starting-point of the fe-
brile phenomena in the nervous system alone — whether
this be the central nervous system according to Virchow, or
the sympathetic system of Claude Bernard, or the trophic
nerves of Schiff— have neither been supported by clinical
facts nor by experimental physiology. Mr. Teale's re-
markable case, in which an injury about the upper part
of the spine was followed by a temperature ranging for
nine weeks from 109° to 122°, and even to 125°, with recov-
ery, can not be taken as a proof that in all cases of fever
the nervous system is at the root of the disturbance. Ami
though 1 may omit the question of local myelitic inflamma-
tion as an agent in causing the febrile movement, this case,
in my opinion, proves possibly just the opposite. In no
other fever is there such a tolerance of an enormously high
temperature, and, if in the great majority of cases even
572
MERZBA Off: THE GENERAL PATHOLOGY OF FEVER.
|N. Y. Mm.. )..f k.,
much lower temperatures become fatal after a shorter time,
this shows that there must be other factors in play.
No one of these factors, therefore, sufficiently explains by
itself the pathogeny and semeiology of fever ; it remains to
be supposed that either two or all three of these factors are
combined. The facts only justify us in the assumption that
during fever heat-production is moderately and constantly
increased, while there is an impaired action of the skin
by which the loss of heat is diminished. The share of the
nervous system has to be stated as being obscure till ex-
perimental physiology sheds a more satisfactory light on
the relation between the phenomena of normal animal heat
and the nervous system.
There are certain symptoms pretty constant in all fevers
which require our attention. Of course, the chijl is one of
the most interesting of them, but, like so many other inter-
esting phenomena in medicine, difficult of explanation. It
consists of a diminution of the peripheral temperature, with
a rise of the internal temperature, which occasionally attains
its maximum at the termination of the chill, more frequent-
ly in the subsequent hot stage.
The fluctuations of temperature are, as is well known, of
a different type in different fevers, and therefore can not be
subject to general laws. The different types — as intermit-
tent, remittent, continuous, and ephemeral, and the reasons
for this nomenclature — are so well known that their enumera-
tion may be sufficient. The division into febricula, pyrexia,
and hyperpyrexia is useless, because of the difference in
the subjective view of the observer.
The influence of fever on the pulse will not only vary
with the degree of temperature and the time the organism
is exposed to the influence of a high temperature, but also
with the cause producing the fever. The pulse will nearly
always be accelerated ; in the beginning it is hard and full,
and becomes smaller and softer in proportion to the inten-
sity and the duration of the disease.
The blood is not altered so much during the fever as
was formerly believed. The relative proportion of haemo-
globin and red blood-corpuscles to the mass of blood is
only slightly diminished. In the lytic or epicritic period
this diminution is considerable.
The carbonic acid given off by the lungs is increased in the
proportion of eight to seven of the normal evolution. That
the respirations are increased in fever is well known ; in
attempting to explain this fact we again meet the dilemma,
Is this due only to the increased temperature, or also to
nervous influence ?
The urine is, during pyrexia, most frequently smaller in
quantity, dark colored, and shows the following chemical
changes :
The relative amount of phosphoric acid is diminished ;
we know that in certain conditions of chronic irritation the
brain is relatively richer in mineral substances than normal-
ly ; it is possible that the acutely irritated condition during
fever depends on the same cause. Chlorate of potassium
is present in moderate quantities, and chlorate of sodium in
small amount. In opposition to former opinions, more re-
cent researches have shown that urea is not increased to a
great extent, while the uric acid and ammonia are present in
greater quantities than normally. While this shows that
the combustion of albuminous substances is increased, it
also demonstrates that the process of disintegration is of
such a nature as to prevent the formation of the normal
terminal product. Albumin we only find in very intense
fever, and the albuminuria may be due partly to altered
conditions of the blood-pressure, partly to the parenchyma-
tous degeneration of the kidneys, partly to an altered dif-
fusion of albuminoids, and possibly to nervous influences.
Of other secretions, that of the salivary glands has been
examined. It is diminished in quantity, sometimes absent
altogether ; its reaction is acid, although a free acid has
not been determined as yet. In connection with the parotid
gland, the suggestion of Mosler, to introduce a cannula into
Stenson's duct for the removal of obstructions, is well worth
mentioning, because in this way the post-febrile inflamma-
tion of the parotid may be prevented or its occurrence di-
minished.
There is a marked degree of dryness of the buccal and
pharyngeal glands, and in almost all fevers we find a buccal
and pharyngeal catarrh, by which the excessive thirst is
better explained than by the so-called febrile desiccation.
That there is a most intimate connection between the dry-
ness of the buccal and pharyngeal mucous membranes and
high temperature is shown by the moist state of the tongue
after severe haemorrhages and subsequent collapse in ty-
phoid fever. The increase in thirst and consumption of
water, with the diminution of the secretions, naturally lead
to the question, What becomes of the water ? It has been
claimed that it becomes latent in the body during the fever,
to be removed from it by the critical discharges. In sup-
port of this view, it has been said that the face of the pa-
tient during pyrexia looks turgid, while during the period
of convalescence the countenance looks most emaciated;
besides, that the blood of the fever patient was supposed to
be richer in water than that of the normal system. The
last point has not been demonstrated with sufficient exact-
ness and conclusiveness to be taken as a proof. In order to
settle the question satisfactorily, it will be necessary, in com-
paring healthy individuals with fever patients, to measure,
besides the water in liquid form, the exact amount of liquid
the normal individual takes in in the shape of solid food — as
vegetables, etc. ; furthermore, the increase in the amount of I
insensible perspiration and exhalation from lung and skin
has to be calculated more accurately than has been done
hitherto.
The anatomical changes which embrace the liver, kid-
ney, spleen, pancreas, the heart muscle, blood-vessels, and
the voluntary muscles, are only to be found after some dura-
tion of a high temperature. The parenchymatous degenera-
tions of the liver and kidneys are easily explained by the
high temperature and perverted innervation ; in the kid-
neys the irritating character of the substances to be secreted
may be of influence.
The heart muscle becomes very soft and pigmented,
being filled with fat granules and brown pigment granules. ,
The walls of the smaller blood-vessels often undergo fatty
degeneration (thence tendency to capillary hemorrhages) ; in
the larger vessels the intima is swollen. In the voluntary
Nov. 21, 1885.]
muscles we find two kinds of degeneration : the fatty and
amyloid. It need hardly be mentioned that the latter does
not allow of restitution. The spleen is enlarged ; in the be-
ginning it is hard and tense, while in the further course of
fever it becomes softer and more friable ; whether the gen-
eral anaemia corresponding with the enlargement of the
spleen is due to the circumstances that this organ deprives
the other tissues of a great amount of blood, or whether it
is due to a specific action of the spleen in the formation of
blood-corpuscles, can not in the present state of physiology
be decided. •
The symptoms connected with the digestive tract are
not always due to a gastro-enteritis, which, with some pa-
thologists, plays such an important part. The anorexia,
constipation, nausea, etc., can easily be explaiued by a lesser
activity of the glands and by faulty innervation. Inflamma-
tion would not be so cfuickly removed as to allow appetite
and digestive power to come back to their normal standard
immediately after the cessation of the high temperature. I
do not wish to assert that the influence of high temperature,
undulv prolonged, may not be capable of producing inflam-
matory lesions of the stomach and intestines, but I do not
believe in their constant presence in fever.
The functional derangements consist of a disturbance of
general sensation and of psychical and motory functions.
The ways in which these disturbances manifest themselves
to the observer are so well known that they do not re-
quire special enumeration.
This completes the symptoms and phenomena which
are more or less constant in all fevers ; special lesions and
their modifying influence on the course of the fever, as the
intestinal lesion in typhoid fever or the skin lesion of variola,
must be left to the consideration of special pathology.
COCAINE IN MINOR OPERATIONS.
By HENRY A. DU BOIS, Ph. B., M. D.,
SAN RAFAEL, CAL.
The following cases, in which this agent was used, may
possess some slight interest :
A boy, aged twelve, had a flap of skin eight inches in length
torn diagonally across the leg, just below the knee, by a kick
from a horse. The wound was free from dirt, as the pantaloons
were not torn. It was well washed with a l-to-2,000 corrosive-
sublimate solution, and a two-per-cent. cocaine solution in gly-
cerin painted on the edges through which stitches were required.
The cocaine solution was exhausted before the entire border of
the wound had been coated. Twelve stitches were then taken,
ten without any pain while conversing with the patient, but the
last two caused great pain. The line of union was covered with
subnitrate of bismuth, and a pad of absorbent cotton applied and
retained by a bandage. Stitches removed on the fourth day.
The wound united, except along the skin-border, which showed
no union. Adhesive straps retained the flaps in position, and I
saw the patient no more, but was told that the wound was fully
united in less than a week.
A man, aged sixty-rive, who had been partly paralyzed,
asked for removal of small growth from the skin of the forearm.
I had removed a similar growth several years before. The new
growth was non-malignant, but started from the old one. I
injected a four-per-cent. solution of cocaine under the bone by
573
four punctures with a hypodermic syringe, and removed a piece
of skin, one and a half by one inch, going down well upon the
muscles. This was done during conversation, and without any
sign of pain on the part of the patient. The wound was drawn
together by sutures, as in the previous case, of silkworm-gut
carbolized, and a bismuth and absorbent dressing applied, but
the forearm was not put in a splint. The movements of the
hand apparently tore out some of the stitches and more or less
suppuration ensued, the wound gradually closing by granula-
tion, but the time was upward of a month ; at no time was
there any pain.
I believe in both these cases the cocaine prevented union
by first intention. In the first case I should have expected
union of the greater portion of the skin-border in four days ;
in the latter, more or less adhesion between skin and sub-
jacent tissue, although, doubtless, movements of the wrist
interfered somewhat with perfect apposition — had I not
used the cocaine, but simply contented myself with wash-
ing the wound with corrosive-sublimate solution and with
dry bismuth dressing. In the latter case, too, the healing
power was also probably deficient. In a small fistula of the
anus the cocaine enabled me to lay it open and apply nitric
acid without pain, and I noticed no postponement of healthy
granulation.
In a case of chronic eczema of the face of fourteen years'
standing, in which it became necessary to remove the beard
on one side of the face, an injection of a four-per-cent. solution
over the trifacial nerve, as it comes out in front of the ear,
enabled me to remove every hair at two sittings and with-
out pain. Applied to the inflamed base, or to the pustules
after matter had been let out, I could detect no relief experi-
enced from the interminable itching, which almost drove the
patient wild ; while a constant current of galvanism, passed
from the front of the ear to the cheek and chin for ten min-
utes, would relieve the itching almost entirely for some eight
hours.
In a case of severe neuralgia of the trifacial nerve in-
volving the branches to the upper and lower jaw I injected
one fifth of a grain of cocaine twice in front of the ear quite
deep into the tissues. After each operation the woman be-
came excited for five minutes or so, but there seemed no
relief from pain, which was only afforded by opium and
chloroform. In a severe case of rheumatic sciatica a hypo-
dermic injection of one fifth of a grain afforded no relief,
while the same quantity of morphine relieved pain, and a
daily application of the constant current effected a perma-
nent cure.
An application to the gum of a few drops of the two-
per-cent. solution enabled a tooth to be extracted with
hardly perceptible pain, while its introduction into a cavity
where the nerve was supposed to be exposed seemed to
afford no relief to pain. Cocaine seems to me to act
through the mucous membrane and through the cellular
tissue, but so far I have seen no action from a direct appli-
cation to a nerve or to the skin. Even when the latter is
excoriated, and when cocaine is injected into the cellular
tissue or applied to the edges of a wound, it certainly seems
to interfere with prompt union. I have so far made no
experiments with this agent on blistered surfaces or burns.
The cocaine used was procured from Dr. Squibb.
DUBOIS: COCAINE IN MINOR OPERATIONS.
574
BOOK NOTICES.
[N. Y. Mkd. Jour,
|looh flotices.
The Use of the Microscope in Clinical and Pathological Exami-
nations. By Dr. Carl Friedlaender, Privat-Docent in
Pathological Anatomy at Berlin. Second Edition, Enlarged
and Improved, with a Chromo-lithograph. Translated, with
the permission of the Author, hy Henry 0. Coe, M. D.,
M. R. C. S., L. R. C. P. (London), Pathologist to the Woman's
Hospital in the State of New York. New York: D. Apple-
ton & Go., 1885. Pp. x-195. [Price, $1.50.]
This book is one of the most concise and comprehensive
guides in technique which the student can obtain who under-
takes microscopical examinations for clinical and pathological
ends. It is divided into seven chapters, in which are described,
in a plain, practical manner, the microscope and its accessories,
reagents, micro-chemistry, methods of preparing specimens for
examination, both of living and of dead tissues, the examina-
tion of fluids, the examination of tumors, etc.
Some beginners in microscopy are very apt to think that the
work is essentially mechanical, and that if the mechanical pro-
cess is perfect the desired pathological knowledge can be ob-
tained readily ; but this source of error is pointed out distinctly
by the author. Another fundamental truth has also been men-
tioned, and that is that there are a number of minds which
either never attain to a capacity for the more delicate histologi-
cal examinations, or succeed only after long and painful train-
ing, and, it may be added, especially painful to the teacher. If
these two ideas can become wide-spread, Dr. Coe, by his excel-
lent translation, will have conferred a lasting benfit upon those
who are interested in this department of scientific work.
The chromo-lithograph is an agreeable addition; but as one
looks at the illustrations he may be led to wonder why pictures
of the same objects are made to appear so different in different
standard books.
A Guide to American Medical Students in Europe. By Hexry
Hun, M. D., Lecturer on Diseases of the Nervous System in
the Albany Medical College. New York : William Wood
& Co., 1883. Pp. vi-151.
This little book was received some months ago, and deserved
an earlier notice. We commend it most heartily to the careful
consideration of the class of readers for whom it is intended.
We have no hesitation in saying that the author is a real bene-
factor to his younger medical brethren, in that he removes one
of the most serious obstacles to the enjoyment and profit of a
foreign trip. To know how, where, and what to study is half
of the battle, and we congratulate Dr. Hun upon having so
clearly and thoroughly discussed these questions. The author's
introductory remarks are sensible and to the point. He dis-
courages the student from going abroad to study until he has
served his time in a hospital. Moreover, he deprecates too long
a stay in foreign parts. " All 'of the time," he says, " that he
(i. e., the student) spends in Europe beyond two years is very
apt to be to his disadvantage." This is an important and, as
regards the average medical student, a true remark.
The statement regarding finances is judicious. We are glad
to see that no attempt is made to impress the reader with the
false notion that his expenses in Europe will fall far below his
home expenditures. Men are frequently sadly disappointed at
the unexpected demands upon their resources when they have
been told that they could live abroad for "about one half" of
what it costs in America.
We call particular attention to the advice as to learning Ger-
man, for it is sound. The caution to students not to travel
about too much from place to place, but to spend all of their
time at two or three of the best medical centers, will commend
itself to all who have had a practical acquaintance with foreign
study. The general hints as to methods of study are worth a
careful perusal.
In giving details about the different German cities, the
author dwells with special care upon Vienna, Berlin, and Leip-
sic. Except in the matter of unimportant facts, such as vary
from year to year, the information is clear and accurate. Medi-
cal study in France is not very strongly advised by the author,
but he presents quite fairly the advantages which Paris offers..
•In treating of the London medical schools, we can not help
saying, a good deal of irrelevant matter might well have been
omitted.
We are glad to read the short section upon the Dublin Ro-
tunda Hospital, since there is a lingering feeling among some
American teachers of obstetrics that the Rotunda is the only
place in which to learn careful midwifery. We believe that this
idea will be exploded, and meantime Dr. Hun is to be com-
mended for coming boldly forward with the statement that
"this hospital offers no advantages for study over those of
Vienna, Prague, or Dresden, except that the English language
is spoken in it."
On the whole, we believe that the "Guide" is an original
book, the material is judiciously selected and arranged, and such
errors as exist are not vital. It would be hardly fair to criticise
too closely the literary style of a work which aims principally
at clearness, rather than elegance, of expression; yet we trust
that the author in his second edition (which we hope to see
soon) will correct some of his awkward sentences, substitute
the word "for" instead of " to " in the title, and add an index.
With these slight emendations, and a condensation of the chap-
ter on England, the little volume will challenge comparison
with far more ambitious works.
System of Practical Medicine. By American Authors. Edited
by William Pepper, M. D., LL. D., Provost and Professor
of the Theory and Practice of Medicine and of Clinical Medi-
cine in the University of Pennsylvania, assisted by Louis
Starr, M. D., Clinical Professor of Diseases of Children in
the Hospital of the University of Pennsylvania. Volume
II. General Diseases (continued) and Diseases of the Diges-
tive System. Philadelphia: Lea Brothers & Co., 1885. Pp.
3-19 to 1312, inclusive.
The general characteristics of this volume are analogous to
those of its predecessor in the series, which it has followed
with commendable punctuality. It even surpasses Volume I in
size, and therein is open to criticism, for its hulk and weight
are such as make it impossible to hold the book with comfort
even in both hands. Another striking feature is the extent and
minuteness of the index, rivaling in this respect the clinical
index, so called, to Bartholow's " Materia Medica and Thera-
peutics," although it does not present the peculiar character
which gives the special name to the latter. An index which
bears to the text to which it refers the proportion of one page
to ten (actually 117 to 1195) should he a remarkably good one
to justify its presence in a volume already so large.
Passing to an enumeration of the individual articles, we find
the opening one, on rheumatism, by Dr. R. Palmer Howard
The second is by Dr. W. H. Draper, on gout, and is an example
of clear and excellent English. While the discussion of the
subject is full, he frankly confesses the limitations of our knowl-
edge as to aatiology and the action of the most potent remedies.
Dr. Jacobi, with an abundant citation of authorities, writes on
rhachitis. Philip S. Wales, M. D., contributes two articles, the
Nov. 21, 1885.J
BOOK NOTICES.
575
one on scurvy, namely, and in the second part that on pseudo-
membranous enteritis. In like manner Dr. I. Edmonson Atkin-
son writes on purpura, and on cancer and lardaceous degenera-
tion of the intestines.
Diabetes is very satisfactorily discussed, in an article of mod-
erate length, by Dr. Tyson, treatment, including the dietetic,
hygienic, and medicinal, occupying much more space than pa-
thology and pathogenesis. Dr. John S. Lynch writes on scrofula,
and Dr. J. William White extensively on hereditary syphilis.
This last author writes with the clearness of conviction so no-
ticeable in the best American authorities on this subject, going
fully and with plentiful references into the knotty question of
the respective shares of father, mother, and foetus in the trans-
mission of the disease, including the curious theory of its latency
in the maternal organism.
Under the subdivision of Diseases of the Digestive System we
find a series of articles by Dr. J. Solis-Cohen on diseases of the
mouth and tongue, of the tonsils, of the pharynx, and of the
oesophagus, organs and regions in connection with which his
name is a guarantee of thoroughness and familiarity. The func-
tional and inflammatory diseases of the stomach are treated of
by Dr. Samuel G-. Armor, and his title is found to include gas-
tralgia. Other gastric affections form the subjects of five arti-
cles by Dr. W. H. Welch, viz.: Simple Ulcer of the Stomach,
Cancer of the Stomach, Haemorrhage from the Stomach, Dilata-
tion, and Minor Organic Affections. These articles are scholarly
and enriched by copious references to literature and citations
from it, while it is very gratifying to find in the matter of treat-
ment especially so much attention given to the details and chem-
istry of alimentation, a remark 'which also applies to Dr. Tyson's
article on diabetes.
Dr. W. W. Johnston writes on various affections of the in-
testines in six consecutive essays.
Dr. J. Lewis Smith contributes an article on the intestinal
affections of children in hot weather. His views are well known,
and it is particularly interesting to know his experience with
the peptonized preparations which have formed such a feature
of the recent management of children's diseases.
Of the remaining articles in the volume, those which will
attract most attention are Dr. Hunter McGuire's on intestinal
obstruction, Dr. Bartholow's treatise on diseases of the liver,
and Dr. Alonzo Clark's on peritonitis. Dr. McGuire's article is
much condensed, and he is forced to relegate much that is ger-
mane to his subject to surgical treatises, since it would be out-
side of the scope of this work.
All graduates of the College of Physicians and Surgeons will
be glad to see the views of the venerable Prof. Clark thus
authoritatively presented on a subject in which he felt so keen
an interest. They will recognize the features which used to
charm them in his lectures, the solid, slightly old-fashioned,
personally characteristic style, with the quaint illustration
drawn from his own experience.
Here is, then, a volume of interesting and valuable essays,
which must still for the present stand chiefly upon their indi-
vidual merits, for the work can not yet be looked upon as a
finished whole, and its claims as a system fairly weighed. As
it stands, it is very attractive, free from disfiguring pages of
advertisements, and with illustrations which, if not numerous,
are apposite.
Uinor Surgical Gynecology. A Treatise of Uterine Diagnosis
and the Lesser Technicalities of Gynecological Practice, in-
cluding General Rules for Gynaecological Operations and tho
Operations for Lacerated Cervix and Perineum and Pro-
lapsus of Uterus and Vagina, for the Use of the Advanced
Student and General Practitioner. By PAul F. Mund£,
M. D., Professor of Gynaecology at the New York Polyclinic
and at Dartmouth College, Gynaecologist to Mount Sinai
Hospital, etc. Second Edition, Revised and Enlarged, with
three hundred and twenty-one illustrations. New York:
William Wood & Co., 1885. Pp. xxii-552.
(Second Notice.)
We hope to see the question of the " cicatricial plug " cleared
up some day. If it is, it will be by the aid of the pathologist.
It can not be allowed to rest entirely upon the dictum of the
clinician. But it is in vain to argue upon a subject the patholo-
gy of which has been so much neglected. In the section upon
the significance of cervical laceration the author summarizes his
views as follows: "It thus appears that I consider only one
half of all the lacerations of the cei'vix which occur as produc-
ing (symptoms?) and requiring treatment of any kind, and of
these but one quarter, or one eighth of all lacerations, as abso-
lutely requiring Emmet's operation. Surely I can not be re-
proached with being an advocate either of too universal patho-
logical significance or of unconditional operative treatment of
this lesion." The latter, it must be added, is rather an awk-
ward sentence. The description of the operation leaves little to
be desired. It gives the reader as clear a picture of the tech-
nique as could be drawn with the pen. Not a single practical
hint or useful device is omitted. We see the operator at his
work, describing each step as he goes along, beginning with an
enumeration of the instruments and ending when the .patient is
removed to her bed. The possible dangers and complications
of trachelorrhaphy are fully and squarely stated. Whatever
faults Dr. Munde's book may possess, want of frankness is not
one of them. In this lvspect it is the true child of its author.
The subject of perineorrhaphy receives the attention which
ts importance deserves. In his pathology the author leans per-
haps more decidedly toward the "keystone" theory than some
of his confreres. His recommendation of the primary opera-
tion will carry weight, and the description of its performance
(page 487) is a very clever and graphic sketch, which furnishes
a good example of the writer's rapid, nervous style. The de-
tails of the operation, both in partial and in complete lacera-
tions, are exceedingly well given. It is in these practical direc-
tions that the author excels as a teacher and writer. Disserta-
tions upon pathology are not his forte, but in describing gynae-
cological manipulations, as he has practiced them himself, he is
perfectly at home. The operation proposed by Dr. Emmet,
which, as Dr. Munde remarks, is properly designed for the cure
of proctocele, is duly described and figured. The author seems
to have formed as clear an idea of the operation as any one has
done, but we question most emphatically the statement that in
passing the sutures they "are carried deep into the furrow and
entirely under the raw surface, so as to pick up the separated
fibers of the pelvic fascia." Even granting that the pelvic fascia
has become detached (which is not by any means certain), how
can the operator be sure that he is "picking it up" when he
does not know where the torn fibers are? Dr. Munde concludes
that the new operation will "not supersede the old, except in
comparatively slight external lacerations, where the redundancy
and prolapse of the posterior wall predominates."
The various operations for the cure of cystocele, proctocele,
and prolapsus are briefly described and figured. Reference is
made to Emmet's " button-hole " ; but it should bo nieutioned
that urethrocele is only one of several conditions for the relief
of which an artificial urethro-vaginal fistula is made by the
proposer of tho operation. Wo are glad to see that prominence
has been given to Lo Fort's operation for the cure of complete
procidentia, for it deserves ft more thorough trial in this country
than it has had hitherto.
576
BOOK NOTICES.
[N. Y. Med. Joor.,
The latter part of Dr. Munde's work bears evidences of
hasty composition. After devoting ample space to trachelor-
rhaphy and perinfflorrbaphy, he dismisses some of the other
operations in a few words. The impression which the reader
receives is that the author found that his book was assuming
too great proportions, and resolved to condense it, even at the
risk of giving it an appearance of unevenness and want of sym-
metry.
We have already referred to the chief excellence of the
book — its practical character and the sound common sense
which pervades it. The style is not always the most pleasing.
While it is frequently clear and concise, it is sometimes rather
involved. The author excels in descriptions; the purely didac-
tic portions are occasionally marred by complicated sentences.
The work is the product of years of experience and observa-
tion, and may be safely relied upon as being the outgrowth of
the writer's own practice. He makes few statements which
have not stood the test of his own judgment. Although there
is much that might have' been omitted without detriment either
to the book or to its author's reputation as a careful writer, as
it stands it will long continue a standard text-book.
Diseases of the Urinary and Male Sexual Organs. By William
T. Belfield, M. D., author of " Relations of Micro-organisms
to Disease " ; Pathologist to the Cook County Hospital, etc.
New York : William Wood & Co., 1884. Pp. vii-351.
The author states in his preface that the present work was
prepared hastily and without sufficient time being allowed for
revision. There are certainly but few signs of such haste, ex-
cept in the last four chapters. The matter is well arranged,
and prominence is given to several topics which have hitherto
received but scanty notice in American treatises on urinary
surgery. Following the German school, Dr. Belfield enters mi-
nutely into the anatomy of the subject, and devotes several
chapters to the examination of the patient, one of which in-
cludes an admirable resume of endoscopy. The physiology and
pathology of the urine are as thoroughly discussed as is possible
in a few pages. Chapters XVIII and XIX, on diseases of the
kidney and bladder, are brief but satisfactory. We may add,
with reference to that portion of the volume which is devoted
to the diseases of the urinary organs, that it is excellent through-
out, and the only regret in the reader's mind when he has fin-
ished it is that the book does not conclude here. The last forty
pages, which treat of sexual disorders, are by no means so credit-
able to the author, since they bear evident marks of rapid com-
position and an apparent haste to finish as soon as possible.
Dr. Belfield has no reason to feel dissatisfied with his work_
It is largely German in its tone, but it is in no sense either a
compilation or an imitation. The author shows a personal
knowledge of his subject, and many of his statements are
founded upon the results of his own experiments.
It is hardly necessary to say that the reader will find in this
book all of the latest ideas concerning urethral fever, as well as
a clear and intelligible description of the methods of using
Griinfeld's instruments, catheterizing the ureters, exploring the
bladder through a perineal incision, etc. Nearly all of the
woodcuts illustrate urinary sediments.
Medical German. A Manual designed to aid Physicians in their
Intercourse with German Patients, and in reading Medical
Works and Publications in the German Language. By Solo-
mon Deutsch, A. M., PIi. D. New York : J. H. Vail & Co.,
1884. Pp. v-336.
Tins will be found a most useful little book, especially for
students who are contemplating a trip abroad. Written after
the style of Ollendorf (though more dignified in its form), it con-
tains just such dialogues as occur so often at the bedside and in
the clinic. The first half of the volume contains a list of nearly
six thousand words, such as are apt to occur in German medical
works or lectures. The criticism to be made here is that the
different parts of speech are bundled without regard to their
relative importance or alphabetical arrangement. This fault is
partly atoned for by the addition of a full English and German
index at the back of the book.
The form of the dialogues is briefly this: A patient enters
with bronchitis. " Where do you feel pain ? " asks the physi-
cian. "I have soreness behind the breast-bone, and pain in my
limbs," replies the patient, and so on.
When we remember how An'iericans of old were obliged to
learn their medical German without special lexicons and other
helps, such as the present manual, we can not be surprised at
the fact that '"studying abroad" was a far more formidable
undertaking than it is now.
BOOKS AND PAMPHLETS RECEIVED.
A System of Practical Medicine. By American Authors.
Edited by William Pepper, M. D., LL.D., Provost and Professor
of the Theory and Practice of Medicine and of Clinical Medi-
cine in the University of Pennsylvania. Assisted by Louis Starr,
M. D., Clinical Professor of Diseases of Children in the Hospital
of the University of Pennsylvania. Volume HI. Diseases of
the Respiratory, Circulatory, and Haematopoietic Systems.
Philadelphia: Lea Brothers & Co., 1885. Pp. 9-19 to 1032,
inclusive.
Tratado Practico de las Enfermedades de las Mujeres. Por
el Doctor Gaillard Thomas, Profesor de Obstetricia y de Enfer-
medades de las Mujeres y delos Ninos del "College of Physi-
cians and Surgeons " de Nueva York, etc. Segunda Edicion
Espafiola, Corregida y Aumentada con Seis Capitulos, Ciento un
Grabados Nuevos, Multitud de Notas de la Ultima Edicion In-
glesa, un Pr61ogo, y un Apendice Terapeutico, por el Doctor
Juan Garcia Puron, Ex-Medico-Cirujano del Ejercito Mexicano,
etc. Nueva York: D. Appleton y Ca., 1885. Pp. xxvi-888.
Epitome of Diseases of the Skin. Being an Abstract of a
Course of Lectures delivered in the University of Pennsylvania
during the Session of 1883 and 1884. By Louis A. Duhring,
M. D., Professor of Skin Diseases. Reported by Henry Wile,
M. D., Clinical Assistant in the Department of Skin Diseases in
the University Hospital. Philadelphia : J. B. Lippincott Co.,
1886. Pp. iii-13 to 130, inclusive. [Price, 60 cents.]
A Guide to the New Pharmacopoeia (1885). Comprising an
Epitome of the Changes, and an Account of the New Prepara-
tions, their Characters, Uses, Doses, and Modes of Administra-
tion ; together with a Therapentical Commentary. By Prosser
James, M. D., Lecturer on Materia Medica and Therapeutics at
the London Hospital, etc. London: J. & A. Churchill, 1885.
Pp. viii-108.
The Externa] Therapeutics of Pulmonary Consumption.
Third Paper. By Thomas J. Mays, M. D., Philadelphia. [Re-
printed from the "Medical News."]
A Case of Traumatic Aneurysm of the Axillary Artery, etc.
By L. S. McMurtry, A.M., M. D., Danville, Ky. [Reprinted
from the "Journal of the American Medical Association."]
Report on the Chemical Examination of the Waters of the
Public Wells of Albany, N. Y. By Willis G. Tucker, Ph.D.
Transmitted to the Board of Health, July 20, 1885.
Suggestions on Some Symptoms of Renal Disease and their
Management. By Charles W. Purdy, M. D., Chicago. [Reprint-
ed from the "Journal of the American Medical Association."]
Annual Announcement of the New York Polyclinic. 1885-
1886.
Nov. 21, 1885.J
LEADING ARTICLES.
577
4 THE
NEW YORK MEDICAL JOURNAL,
A Weekly Review of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Posteb, M. D.
NEW YORK, SATURDAY, NOVEMBER 21, 1885.
PASTEUR'S PREVENTIVE INOCULATION OF HYDROPHOBIA.
In another part of this issue we reproduce from the " Medi-
cal Times and Gazette," of London, a hrief but very satisfactory
account of M. Pasteur's system of protective inoculation of
rabies. Under any circumstances, the results which M. Pasteur
has been enabled to report to the Academie de medecine could
not fail to prove of surpassing interest, but just at the present
time they seem to come most opportunely, for hydrophobia is
so prevalent in England as to be termed epidemic, and many
oases have lately been reported in Paris.
It would be premature to settle down to the conviction, on
the strength of Joseph Meister's case, that an infallible pre-
ventive had at last been found of a disease which, although,
fortunately, of comparatively rare occurrence, is undoubtedly
the most horrible in all our nosology, whether we regard the
torturing uncertainties of its variable and often extremely pro-
tracted period of incubation, the uniformity with which it
destroys life, or the terrible suffering that attends its course.
But, while we would not hastily accept this comforting con-
clusion, on the other hand we have little patience with the per-
tinacious objectors who seem bent on belittling every step in
Pasteur's course of investigation, and ready to attribute Meis-
ter's escape thus far to anything but the inoculations. Almost
«very innovation in medicine has to encounter a hand-to-hand
resistance. Tantalizing a3 the process is, it is not wholly a dis-
advantage, for it guards against our falling lazily into a blind
acceptance of what happens to be at the same time plausible
and agreeable. In our estimate of such a matter as the Pas-
teur system of inoculation, we should divest ourselves alike of
credulous enthusiasm and of over-skepticism.
The main considerations to be taken into account are,
briefly, these: The dog that bit young Meister was not abso-
lutely proved to have been mad. As is too often the case, it
was killed before the clinical features had declared themselves
unmistakably. Nevertheless, so long as it was permitted to
live it showed the symptoms common to dogs in the early stage
of the disease, and at the post-mortem its stomach was found
stuffed with the refuse that competent observers have declared
to be a conclusive sign of the depraved appetite characteristic
of hydrophobia. The boy was terribly bitten, not in one place,
but in many, and in portions of the body where the probability
of inoculation is at its highest. The cauterization was not
done until twelve hours after the bites had been inflicted ; it
was then done, not with a hot iron, but with carbolic acid, and
we are told that some of the wounds were not cauterized at all.
But, even if we admit that the cauterization protected the boy
against hydrophobia as the result of the bites, we can not for a
moment entertain the idea that it also rendered him proof
against the fatal result that would, almost to a dead certainty,
have followed M. Pasteur's inoculation of the intensified virus,
except for the protective effect of the preparatory inoculations.
Even the theoretical objection that the rabies of rabbits is not
communicable to other than herbivorous animals fails to break
the force of this last statement, for Pasteur himself has shown
that it can be communicated to the Carnivora. Unless, as the
" Gazette hebdomadaire de medecine et de chirurgie " suggests,
we are content to rest our last doubt on the insufficient time
that has elapsed since Meister was bitten, we must conclude,
then, either that he has been saved from hydrophobia by M.
Pasteur, or that he was born into the world with a most re-
markable immunity. It is true that the period of incubation is
sometimes very long, and that but little more than three months
have elapsed since Meister was last inoculated ; but in most cases
the disease declares itself within that length of time, especially
in the young. In view of all these considerations, we must
admit that the probabilities are gratifyingly in favor of the
belief that M. Pasteur lias at last succeeded in furnishing us
with a means of preventing this terrible disease, but, of course,
time alone can confirm or overturn our expectations.
THE PROPOSED REGULATION OF MEDICAL PRACTICE IN
THE STATE OF NEW YORK.
The president of the New York State Medical Association,
in his address delivered before that body last Tuesday, took
decided ground against State legislation intended to affect
medical education. It is well known that for two or three
years past the Medical Society of the State of New York —
and our distant readers should bear in mind the distinction
between the two societies — has been trying to obtain such
legislation as would make the right to practice depend upon a
State license. The prevailing idea has been that this license
should be granted only after a State examination, regardless of
candidates' diplomas. Legislation of this sort would, of course,
have an effect upon the teaching in the medical colleges of the
State, but the effect would be an indirect one, bearing scarcely
more upon the New York colleges than upon others, and that
it would be wholesome there can be no doubt. It certainly
need not involve any interference with the curriculum of a col-
lege or with its methods of teaching.
There is no lack of honest and capable men who are op-
posed to such legislation, or at least distrustful of it, and it
must be confessed that the questions involved in the project
are by no means easy of solution, but it is somewhat disheart-
ening to find such an issue raised in connection with it as one
of those which were raised in the address alluded to — both
because we think the issue irrelevant and because we thiuk
that the implied appeal to the material interests of the Now
York colleges is one that they themselves would scarcely feel
comfortable in urging upon the attention of the Legislature.
Dr. Gray expressed his apprehension that the legislation
proposed would "transfer students who came to the medical
colleges of New York from all parts of the country, and from
578
MINOR PA RAO RAPES.
[N. Y. Mki>. Jopb,,
foreign countries, to the schools of Boston, Philadelphia, and
other cities." We have before heard this fear expressed in
private, but never before, so far as we are aware, has it been
put forward in public. We do not believe that the profession
of the State would attach much weight to an argument of this
sort, even if it were well founded, which it certainly is not, in
our opinion ; for it plainly puts self-interest above all other
motives, and it is in no such temper that the Medical Society
of the State of New York has taken up the question. We can
not, indeed, think that the colleges are willing to put them-
selves publicly in the position of trying to obstruct legislation
in the interest of progress simply because they think they may
lose a few students.
Unless Dr. Gray's understanding of the proposed legislation
differs radically from ours, he can only have had in mind the
regulation of the right to practice by the State, and not any
interference with the college requirements for graduation. As
we view the matter, there is not the slightest danger that such
legislation will work the least injury to the colleges. The ques-
tion will be as to the means of obtaining a license to practice in
this State, and the graduate of a New York college will not be
at any disadvantage. Students who intend to practice in this
State will not be enabled to slip through any more easily by hav-
ing taken their college courses or their diplomas elsewhere, and
those who intend to practice in some other State will in no wise
be affected by the New York law. We do not believe, there-
fore, that the legislation in question will lead a single student
away from New York.
MINOR PARAGRAPHS.
THE NEW YORK STATE MEDICAL ASSOCIATION.
As we go to press, the second annual meeting of the associa-
tion is in progress at fcfee Murray Hill Hotel, and we give a por-
tion of the proceedings in this issue of the Journal. The neces-
sity of holding evening sessions testifies to the amount of work
that is being done, and, judging from the reports of the pro-
ceedings thus far received at this office, we feel safe in saying
that the quality of the papers read is in general quite up to
what was expected of this new and energetic body. A particu-
larly commendable feature of the programme is the grouping of
papers dealing with the same subject from different points of
view. The attendance is large and representative of the various
sections of the State, and the meeting must be said to be de-
cidedly successful.
NEWS ITEMS, ETC.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending November 17, 1885 :
DISEASES.
Week ending Nov. 10.
Week ending Nov. 17.
Cases.
Deaths.
Cases.
Deaths.
0
0
3
0
23
6
25
8
Scarlet fever
20
5
21
0
Cerebro-spinal meningitis. . . .
1
1
4
4
5
1
13
4
56
25
59
28
8
2
7
2
The Health of Foreign Cities.— We are indebted to the
secretary of the National Board of Health for the following ab-
stract of reports from our consuls, received at his office since
the date of the last bulletin, November 11th : Montreal, Canada.
— For the week ending November 1 1th : 143 deaths from small-
pox in the city, and 93 in adjoining municipalities as compared
with 233 and 89, respectively, during the week ending Novem-
ber 4th. Reports received at this office indicate that the num-
ber of deaths occurring in the city from the disease is steadily
declining, while the area of the infected district beyond the city
limits is as steadily increasing. Twenty-nine [daces were re-
ported infected November 7th. The City Auditor of Montreal
reports, under date of November 5th, an expenditure of $40,-
799.79 in connection with the epidemic, and states that he be-
lieves the total expense to that date will reach $100,000. King-
ston, Canada, November 13th : Free from small-pox. Toronto,
Canada, November 7th : Free from small-pox. Matanzas, Cuba,
November 4th : Free from epidemic diseases. Nassau, X. P.,
October 24th: Free from epidemic diseases. Acapulco, Mexico,
October 25th : Health of city improving. Guaymas, Mexico. —
For the month of October: 6 deaths from yellow fever. No
cases of fever have been reported at other towns in the consular
district. Buenos Ayres. — For the month of May: 92 deaths
from small-pox. London, England. — For the week ending Oc-
tober 31st: 9 deaths from small pox. Cases in hospital, 88;
admissions during the week 14, as against 11 in the preceding
week. Paris, France. — For the weekending October 31st: 8
deaths from small-pox. Bordeaux, France. — From October
17th to 31st: 5 deaths from small-pox. Antwerp, Belgium. —
From October 17th to 31st: 3 cases and 2 deaths from small-
pox. Copenhagen, Denmark. — For the month of September:
45 deaths from small-pox. Zurich, Switzerland. — For the week
ending October 21st: 2 deaths from small-pox. Prague, Bohe-
mia.— For the week ending October 29th : 7 deaths from small-
pox. Trieste, Austria. — From October 10th to 24th: 15 cases
and 4 deaths from small-pox. Barcelona, Spain. — From October
10th to 20th: 169 cases and 78 deaths from cholera. October
18th to 20th, no new cases or deaths reported. Cadiz, Spain. —
For the week ending October 31st: Cholera has disappeared,
and clean bills of health are to be issued after November 1st,
Gibraltar, Spain. — For the week ending October 25th : No
new cases of cholera since October 13th. Sporadic cases still
reported in neighboring Spanish villages. Dengue prevalent.
Genoa, Italy.— From October 18th to November 1st: 20 cases
and 1 death from small-pox. Leghorn, Italy. — For the week
ending October 25th : 1 death from small-pox. Venice, Italy. —
From October 3d to 17th : 16 cases of small-pox. St. Peters-
burg, Russia. — For the week ending October 24th : 1 death
from small-pox. Warsaw, Russia. — From October 3d to 17th:
3 deaths from small-pox. Calcutta, India. — From September
19th to October 3d: 13 deaths from* cholera and 1 from small-
pox. Hioga, Japan. — For the week ending October 10th : 22
cases and 21 deaths from cholera.
Scarlet Fever in Boston. — It is reported that the disease
is increasing in certain portions of the city.
The Sanitary Inspection on the Canadian Frontier. —
Under date of November 10th, Surgeon H. W. Austin, of the
Mai ine-Hospital Service, reports to Surgeon-General Hamilton
as follows :
"I have the honor to report that I completed the inspection
of all Vermont stations November 6th, and then returned to
Burlington, Vt. Awaiting my return was a large amount of
mail requiring immediate attention, and, having no clerk, it con-
sumed considerable time to dispose of it ; hence the delay in re-
Nov. 21, 1885.]
MINOR PARAGRAPHS.
579
porting the result of my inspection. Considerable complaint
was heard that only a part of Montreal baggage was disinfected
at our stations, and that it must be done at the points of destina-
tion. To satisfy local and State health officers, and in order
that every possible precaution might be taken, I issued an order
to all Vermont inspectors, and to the inspectors on duty at
Rouse's Point, to thoroughly disinfect all Montreal baggage, and
this is now being carried out. Each station has a well-equipped
fumigation building, where the baggage is opened and hung up
on hooks, and allowed to remain in sulphurous-acid gas for four
to twelve hours, according to the nature of the articles to be
disinfected. Three pounds of sulphur are burned in one thou-
sand cubic feet of space. The baggage is then carefully put
back into the trunks, which are then checked and sent on to
their destination. Very few certificates of vaccination are at
present accepted by our inspectors, but the arm is examined in-
stead, and all are vaccinated when considered necessary. Large
quantities of freight, consisting of household goods, are disin-
fected at each station. This is generally done in a freight-
car which is suitable for the purpose. To illustrate the
faithfulness or thoroughness with which the work is done
aboard the trains, and the various ways resorted to by cer-
tain emigrants, I will cite a few incidents. At Ogdensburg,
N. Y., an Indian of some Canadian tribe was met on the ferry
by our inspector, and he was asked the question whether he had
been vaccinated. He replied, 'Indian had not been v-accinated
and not propose to be.' He was informed that he would have
to return unless he allowed I he. inspector to vaccinate him. He
reluctantly consented, and when the vessel arrived at port it
was found that he had baggage that required disinfection. To
this he strongly objected, but, rather than have it returned, gave
it over to the inspector, who put it in the fumigation building.
He waited and watched the process with great interest, and, as
soon as the door was opened, plunged into the room where the
smoke was so dense that nothing could be seen, but returned in
a second (well fumigated), but nearly suffocated. He finally re-
ceived his baggage and started. He immediately got drunk,
was put in the lock-up by the city authorities, and was returned
to Canada the next morning, he being without means of sup-
port.
" On one of the trains a woman slipped by the inspector and
entered the water-closet. She was allowed to remain there two
hours, and then a brakeman rapped for her to come out. She
refused to do so, and had to be taken out by force. She was
vaccinated and allowed to pass. Passengers will mutilate their
own arms and produce the wound as evidence of vaccination.
They have been detected in doing this, but it does not often suc-
ceed. They frequently wipe off the virus after they have been
vaccinated, and always, when they are discovered, must submit
to revaccinalion. It will be seen that over certain railroads
twenty per cent, of all passengers are vaccinated. The fumiga-
tion of baggage is performed by the baggage-masters of the dif-
ferent roads, as they requested that they be permitted to do the
work, as they were responsible for the baggage and would be
obliged to oversee the work and look after checks and reship-
ping. This, of course, is done under the direction of the sani-
tary inspectors; but we are obliged to pay the men for this
work, and they are subject to our orders. In this connection I
would like to inform you that the railroad authorities of the
Central Vermont, the Grand Trunk, the South Eastern, and the
Passumpsic have given us every facility to inspect passengers,
baggage, and freight, and have assisted and supported our in-
spectors by every means in their power, and deserve the thanks
of the service and the community generally.
"The inspection of trains is a difficult work, but it is being
done as thoroughly as it is possible to do it. The inspectors are
doing their work well, as I believe the result will prove. I have
been with each inspector in making his trip to Canada and re-
turn, and am satisfied that all understand their duties, and are
doing them well and satisfactorily to all intelligent and unpre-
judiced persons."
The Suffolk District Medical Society.— At the regular
meeting of the Gynaecological Section, held in Boston, on
Wednesday, November 18th, the following papers were read:
" An Unusual Case of Hydatids complicating Labor," by Dr.
W. A. Dunn ; a translated account of " A Successful Case of
Caasarean Section," performed on a Japanese woman by a
young woman recently graduated from an American medical
college, and who went to Japan as a missionary, by Dr. E. W.
Cushing; "The Use of Ether during Labor," by Dr. J. P. Rey-
nolds, who reported seven cases of difficult labor in which ether
had not only relieved the suffering, but had prevented a recur-
rence of complications which had occurred in previous labors
— notably, post-partum haemorrhage in three of the cases. He
favored the general use of ether during labor, as did the gen-
tlemen who took part in the discussion of the paper.
The Hempstead Church Restoration Fund.— Since our
last issue we have received $10 for the fund from Dr. Fordyce
Barker. The total sum now subscribed amounts to $31.
The Vacant Chair at the Long Island College Hospital.
— We have assurances, if any were needed, that the greatest
care will be exercised in choosing a successor to the late Dr.
Armor. Indeed, the charter of the institution provides safe-
guards in this direction such as we should be glad to see im-
posed upon all our medical colleges.
Death from Football having been alleged in the case of a
member of the freshman class at Yale College, who lately died
suddenly of cerebral haemorrhage, Dr. W. O. Ayres and Dr. W.
W. Hawkes, who made the post-mortem examination, have fur-
nished statements which seem to set the suspicion at rest.
The New York Society for the Relief of the Ruptured
and Crippled held its twenty-second annual meeting on Thurs-
day of last week. Eight thousand three hundred and seventeen
new patients were reported to have been treated during the
year.
The New York State Board of Health held a meeting in
New York on Monday, at which the satisfactory character of
the frontier inspection, under the direction of the Marine-Hos-
pital Service, was clearly established.
The late Dr. Alonzo T. Keyt, of Cincinnati.— Dr. Keyt
died suddenly, of cardiae disease, on Monday, the 9th inst., in
his fifty-eighth year. He was a native of Ohio, and had been a
practitioner in Cincinnati for upward of thirty-live years, his
career having been honorable and successful. He was best
known for the invention of a remarkably ingenious cardio-
sphygmograph. At a meeting of prominent members of the
Cincinnati profession, held on the Wednesday following his
death, appropriate resolutions, drawn by Dr. A. E. Jones, Dr.
William Carson, and Dr. W. II. Wilder, were passed, and re-
marks eulogistic of the deceased were made by Dr. C. G.
Comegys, the chairman of the meeting, and by Dr. Carson, Dr.
Dunn, Dr. Jones, and Dr. Kemper.
Army Intelligence.— Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from Xovemher 1 to Xoremhcr 14, 1885:
MoCleli.an, Ely, Major and Surgeon. Leave of absence granted
in orders, Cavalry Depot, Jefferson Barracks, Missouri, Oeto -
580
LETTERS TO
THE EDITOR.
[N. Y. Med. Jocb.,
ber 30th, is extended seven days. S. 0. 254, A. G. O., No-
vember 4, 1885.
Ebekt, R. G., Captain and Assistant Surgeon. Ordered from
Camp Grant, Riverside Park, New York city, to Fort Hamil-
ton, New York Harbor, for duty. S. O. 237, Department of
the East, November 5, 1885.
Bushnell, G. E., First Lieutenant and Assistant Surgeon. As-
signed to duty at Camp Grant, Riverside Park, New York
city. S. O. 237, Department of the East, November 5, 1885.
Baily, E. I., Colonel and Surgeon. Relieved from duty as At-
tending Surgeon, San Francisco, Cal., and ordered for duty
a9 Medical Director, Division of the Pacific and Department
of California. S. O. 260, A. G. 0., November 11, 1885.
Noeeis, Basil, Lieutenant-Colonel and Surgeon. Ordered for
duty as Medical Director, Department of the Columbia. S.
O. 260, A. G. O., November 11, 1885.
McKee, J. C, Major and Surgeon. Ordered for duty as At-
tending Surgeon and Examiner of Recruits, Boston, Mass.
S. 0 . 260, A. G. O., November 11, 1885.
Vollum, E. P., Lieutenant-Colonel and Surgeon. Ordered for
duty as Medical Director, Department of Texas. S. O. 260,
A. G. O., November 11, 1885.
Smith, J. R., Lieutenant-Colonel and Surgeon. Ordered for
duty as Attending Surgeon, New York city. S. 0. 260,
A. G. O., November 11, 1885.
Alexander, R. EL, Lieutenant-Colonel and Surgeon. Ordered
for duty as Medical Director, Department of Arizona. S. O.
260, A. G. 0., November 11, 1885.
Kane, John J., Captain and Assistant Surgeon. Ordered for
duty as Post Surgeon, Fort Ringgold, Texas. S. O. 141,
Department of Texas, November 4, 1885.
Naval Intelligence. — Official List of Changes in the Medi-
cal Corps of the United States Navy for the week ending Novem-
ber U, 1885.
Sayee, J. S., Assistant Surgeon. Detached from Naval Hos-
pital, Mare Island, and ordered to the Omaha.
Dixon, W. S., Surgeon. Detached from Coast Survey Steamer
Hassler upon reporting of his relief, Past Assistant Surgeon
D. 0. Lewis, and to wait orders.
Lewis, D. 0., Past Assistant Surgeon. Detached from naval
rendezvous, San Francisco, and ordered to relieve W. S.
Dixon, Steamer Hassler.
Dungan, J. S., Medical Director. Ordered to naval rendez-
vous, San Francisco, to relieve Past Assistant Surgeon D.
0. Lewis.
Marine-Hospital Service. — Official List of Changes of
Stations and Duties of Medical Officers of the United States
Marine- Hospital Service, for the week ended November 14, 1885.
Wheeler, W. A., Passed Assistant Surgeon. To proceed to
Ontario, Canada, on special duty. November 11, 1885.
Urquhaet, F. M., Passed Assistant Surgeon. To proceed to
Baltimore, Md., with steamer Manhattan, and then rejoin
station. November 12, 1885.
Society Meetings for the Coming Week :
Monday, November 23d: Medical Society of the County of New
York; Boston Society for Medical Improvement; Lawrence,
Mass., Medical Club (private) ; Cambridge, Mass., Society
for Medical Improvement.
Tuesday, November 24th: New York Dermatological Society ;
New York Surgical Society ; Medical Association of Central
New York (semi-annual — Syracuse); Buffalo Obstetrical
Society (private); Boston Society of Medical Sciences (pri-
vate).
Wednesday, November 25th : New York Pathological Society;
American Microscopical Society of the City of New York ;
Philadelphia County Medical Society (conversational); Au-
burn City, N. Y., Medical Association; Berkshire, Mass.,
District Medical Society (Pittsfield).
Thursday, November 26th: New York Academy of Medicine
(Section in Obstetrics and Diseases of Women and Children) ;
Harlem Medical Association of the City of New York ; New
Y'ork Orthopaedic Society; Brooklyn Pathological Society;
Pathological Society of Philadelphia; Roxbury, Mass., So-
ciety for Medical Improvement (private) ; Cumberland Coun-
ty, Me., Medical Society (annual — Portland).
Friday, November 27th : Yorkville Medical Association (pri-
vate) ; New York Society of German Physicians : New York
Clinical Society (private) ; Philadelphia Clinical Society ;
Philadelphia Laryngological Society.
Saturday, November 28th: New York Medical and Surgical
Society.
Inters to % m\ax.
THE PROPOSED NEW NATIONAL MEDICAL SOCIETY.
, Minnesota, November 5, 1885.
To the Editor of the New York Medical Journal:
Sie: Regarding the discussion relating to the formation of
a National Medical Academy I desire to add my mite. My
suggestion is that (a) each subscriber of a medical journal in
tne United States send to the editor of bis journal a list con-
taining one hundred names who he desires shall constitute the
Academy; (b) the editors of the medical journals in the United
States vote for three deans of medical colleges, who shall
constitute a canvassing board to count the votes sent in
by tbe subscribers, announce the result, and name a date
and place for a meeting and organization for the successful one
hundred.
Each editor sends a ballot, on which appear the names of
three college deans, to the surgeon-general of the array, who
canvasses the vote, and the three receiving the highest number
of votes constitute the canvassing board. The surgeon-general
then names a date and place of meeting for this board to can-
vass the general election of tbe subscribers. Each editor sends
the lists received from his subscribers to any member of the
board, who are to meet at the place designated by the surgeon-
general, and count the votes; and the one hundred receiving
the highest number are to constitute the members of tbe
Academy.
When a physician subscribes for more than one journal and
sends more than one ballot, the canvassing board is to decide,
by lot or otherwise, which ballot shall be counted. Each ballot
is to be signed by the voter ; the subscribers to vote in one
month and the editors in the next month.
This plan I submit to the readers of your journal for con-
sideration. It appears to me more simple than the one sug-
gested by your correspondent in No. 361, and would give
every member of the medical profession a voice in the forma-
tion of a body to which he will ever after point with pride.
This is offered " as a labor of love " by one of those who
" have no hope of becoming members of the Academy them-
selves." •
I am, fraternally, W. H.
Nov. 21, 1885.]
PROCEEDINGS
OF SOCIETIES.
581
||rjoceeDings of Sortetus.
NEW YORK STATE MEDICAL ASSOCIATION.
Second Annual Meeting, held in Neia York, Tuesday, Wednesday,
Thursday, and Friday, November 17, 18, 19, and 20, 1885.
The President, Dr. John P. Gray, of Utica, in the Chair.
Tuesday's Proceedings.
The Report of the Council recommended that papers which
were to appear in the volume of "Transactions" of the associ-
ation be not published in the medical journals previously.
The Treasurer's Report showed the total receipts for the
year to have been $2,4G1 ; balance in the treasury from last
year, $083. Deducting disbursements for the year, there re-
mained a balance of $193. For the library fund, the surplus
from anniversary subscriptions last year was $630, $315 of
which had been placed to the account of the building fund.
Excluding disbursements, there remained in the library fund
$31 ; $80 had been subscribed for a binding fund.
Dr. Ferguson offered some amendments to the by-laws, to
be acted upon at the next annual meeting. They referred
chiefly to abolishing the office of corresponding and statistical
secretary, the appointment of a librarian by the Council, and
the striking out of certain words as to the qualifications of new
members.
The President's Address : The Relations of the State to
Medical Science. — The President then read his address, in
which he reviewed the educational policy of the State of New
York, which was confined principally to supervision of the com-
mon schools and of the normal schools in which teachers for
the common schools were trained. The duties of the Board of
Regents were briefly referred to. Law schools, medical schools,
scientific schools, etc., were corporations sustained by private
contributions or their earnings, and were individual enterprises,
receiving no grants from the State. He then asked the ques-
tion, what legislative interference was proper with this class of
institutions which represented scientific education and research.
Whether the State itself should undertake such education as a
public measure constituted a serious question in political econo-
my, and for this State, for the present at least, that question
had been answered adversely. Legislative control over the
medical schools of this State was not demanded by public inter-
est. It was not intended to dispute the power of the Legisla-
ture to regulate medical education and declare what should con-
stitute a doctor in medicine; but the fact was that the Legisla-
ture exercised its power only in the way of fostering, protecting,
and advancing the interests of medical science up to giving the
best opportunities to schools for attaining this end, and at the
same time as far as possible allowing the individual entire free-
dom of special study and of the means for acquiring a knowledge
of medical science. The State had not adopted, and could not
adopt, any particular school or system of medicine as against
others. It was the part of wisdom to give the widest latitude
to discussion wherever matters of opinion seemed to be in con-
flict. The giving to the physician certain powers which the
State had conferred upon him was the highest indorsement
which the State could give the profession. The State had left
the cultivation and development of medical science to the medi-
cal profession alone, and had granted the right to incorporate
societies ai.d associations in order to maintain its unity of work,
and for its elevation and progress. With regard to the services
of the medical profession to the public, little need be said. The
physician's services were sought for by the people in the same
way that the services of the lawyer or any other member of
the community were sought for. As to the matter of granting
diploma5*, and the control of this power by the State, the speak-
er's views were adverse to any such proposed change. The
State did not even attempt to regulate the compounding and
sale of drugs and nostrums. As the State had nothing to do
with the teaching in the schools, so it should have nothing to
do with the examinations. What possible efficiency such a
board of examiners as had been proposed could have in benefit-
ing medical science, the profession, and the people, did not ap-
pear. Such a change would transfer students who came to the
medical colleges of New York from all parts of the country, and
from foreign countries, to the schools of Boston, Philadelphia,
and other cities. The schools had done excellent work in ele-
vating the standard of medical study, and, while there was room
for further improvement, to seek it in the guardianship of the
State was an error. It was true also that the preliminary edu-
cation should be better, and this demand also promised to be
met as soon as the advance of the times would permit.
Reports of the Different Branches of the association were
then read, in which it appeared that a large number of papers
on different subjects connected with medical science had been
read, and other work had been performed. The president of
the New York County Medical Association, Dr. C. A. Leale, also
read the report of the year's work of that society.
The Address in State Medicine.— -Dr. Alfred L. Carroll,
president of the Section in State Medicine, then read his address.
He briefly reviewed state medicine, or sanitary medicine, as it
had existed in ancient times, and said that many excellent rules
were in force among the Israelites which would be of practical
utility if adopted at present. State medicine, in its comprehen-
sive sense, included all the medical interests of the State, but, in
the popular estimation, the term had a narrow significance, being
applied more especially to the practical administration of sani-
tary science for the protection of the public health. Even with
this limited definition, preveutive medicine had presented its
claims with greater vigor than other specialties. Modern sani-
tation might be defined as applied physiology. The sanitarian
should be primarily an accomplished physician, but he should
add to his medical knowledge some theoretical if not practical
knowledge of architecture and engineering. He should know
how to detect defects therein and suggest the remedies. Dr.
Carroll then pointed out some of the conflicting opinions of
sanitary men regarding what constituted sanitary conditions.
The superstructure of public sanitation had to be built upon the
laws of personal hygiene. It followed that enlightenment in
this direction must originate with physicians. As was the seed
sown by medical schools so would be the harvest of public
health. How had these schools fulfilled this condition ? He
would grant that many of them furnished the opportunities, for
a pupil having means and ambition to make use of them, to gain
the necessary education, but what was needed was an enforced
education in all important branches, not leaving their study
optional with the student. He named the studies and time re-
quired for study in England, and said that, while the work
seemed formidable, it would also be seen that the knowledge to
be acquired was not more than every physician should have
when he came to discharge his duties to the public and to pri-
vate patients. In his official relations Dr. Carroll had had an
opportunity of learning what were the acquirements of persons
who sought positions on boards of health, and the answers by
men graduated from regular medical schools had often been ab-
surdly erroneous. Now and then there were marked exceptions,
even in remote country districts. He thought a weakness in the
State and local boards of New York existed in the short term of
office, and in the time spent in inducting new men into strange
duties. The need of a preliminary education and of a higher
582
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jock.,
and more thoroughly enforced medical education was pointed
out.
Tubercular Consumption ; Is it ever Hereditary?— Dr.
Henry D. Didama, of Syracuse, read a paper on this subject, in
which he quoted the opinions of different authors on the sub-
ject of hereditary tendency, hereditary diathesis, etc., and also
the results of post-mortem examinations by various pathologists;
and said that in the examinations ot the bodies of hundreds and
thousands of foetuses none had been found to have tubercle,
which weighed very heavily against the heredity theory. He
also quoted the statistics furnished by insurance companies, by
which it appeared that the majority of cases of phthisis occurred
in persons whose parents had not suffered from the disease.
The following were the conclusions which the author reached:
1. That tuberculous disease was not inherited. 2. That, if a
special tendency to the disease was transmitted, the term lia-
bility better expressed the idea than the term tendency. 3.
That many conditions, such as poor and insufficient food, damp
and impure air, stinted sunlight, and certain occupations, favored
the development ot the disease. 4. That two conditions were
almost indispensable; abundance of bacilli and an inviting asy-
lum for their development, whether the susceptibility was in-
herited or acquired. An important indication was to place the
newly born child of a phthisical mother under the charge of a
healthy wet-nurse, who should occupy a room entirely secluded
from that of the consumptive members of the family. This gave
an opportunity to strengthen the feeble constitution and to
eradicate a liability to the development of consumption. If a
syphilitic taint existed or was suspected, the author advised
antisyphilitic treatment, not only with a view to cure the
syphilis, but also with a view to strengthen the constitution and
guard against the development of phthisis.
Dr. Thomas F. Rochester, of Buffalo, said that some years
ago he made an autopsy on an infant which died three weeks
old. lie found one lung crammed with miliary tubercles, and
in the other there was a cavity of the size of a hickory-nut. The
mother was healthy; the father had died before the baby was
born. In another case, in which the father died before the birth
of the child, and the mother was a healthy woman, having no
tuberculosis, the child died at eighteen months of age, having
had for a long time before death every indication of pulmonary
phthisis, and for a short time of tuberculosis of the vertebrae.
In the light of these cases he could not help believing that,
sometimes at least, phthisis was hereditary. He would admit,
however, that many people had phthisis whose parents had been
free from the disease. The paper was further discussed by Dr.
Colvin, Dr. Pomeroy, and others.
Psoitis and Peripsoitis; their Pathology and Differen-
tial Diagnosis. — Dr. Simeon T. Clark, of Niagara County,
read a paper with this title, in which he first referred to the
paucity of the literature of the subject, and the difficulties at-
tending a differential diagnosis, and then proceeded to give the
clinical histories of three cases which had come under his obser-
vation. In all the cases there had beei a history of traumatism.
In the first case the patient, a woman without children, aged
forty-three, had received a blow on the abdomen, which was
followed by severe pain in the supra pubic region, two inches
from the median line. A hard lump was recognized by the
physician who examined her, from which the pain seemed to
proceed. Nothing was discovered by a vaginal examination.
Dr. Clark saw the patient afterward, and became convinced
that there was suppurative inflammation of the psoas. Pus
was removed, and thirty-one aspirations were made before a
cure was finally effected. The pus did not contain a trace of
phosphate of lime.
The second case was in a yotiug man, whose condition origi-
nated in strains during roller-skating. When he consulted his
physician, Dr. Gould, he complained of pain in the region of
the hip, and had a rapid, bounding pulse, and a temperature of
105° F. Afterward copious perspiration of an acid odor, etc..
led to the diagnosis of rheumatism, but finally a boggy tumor
appeared in the supra-pubic region. An exploratory puncture
gave exit to foul gases, followed by pus. An opportunity to
make an autopsy was afforded in this case, and a psoas abscess
was found, which had led to denudation of the bone beneath.
There was also some softening of the vertebra;, but it was evi-
dent that the disease had originated in the muscle, and not in
the vertebras.
The third case was that of a man who first attributed his dif-
ficulty to rheumatism, from which he had been a frequent suf-
ferer, but it was learned that he had injured himself in the region
of the psoas while throwing tilled sacks upon a wagon. He com-
plained much of pain in the neighborhood of the thigh. The
pain was relieved by a local ana>thetic. A supra-pubic tumor
developed, which, at a time when Dr. Clark had intended to
open it, burst spontaneously into the bladder, and a quart of
healthy pus was evacuated per urethram. Another opening for
the escape of pus was afterward made above Poupart's ligament.
Pus then ceased to escape through the bladder, and finally
through the artificial opening, and the patient went on to com-
plete recovery.
In regard to the differential diagnosis, stress was laid on the
history of traumatism, on pain in the thigh and leg, on the pos-
ture of the patient, who avoided extending and rotating the leg,
on the supra-pubic tumor, and on aspiration letting out lauda-
ble pus. In each of his cases the syringing of the pus cavity
had been followed by washing out with a solution of carbolic
acid.
Dr. Frederick E. Hyde believed that many cases of sup-
posed vertebral disease were really cases of the kind related by
Dr. Clark, and he urged with great earnestness the importance
of making a careful search in suspected cases for a history of
traumatism, for a pelvic tumor, and for pus, by the repeated use
of the aspirator if necessary; for the train of evils following a
change of the laudable pus which was first present into un-
healthy pus was too long and serious to permit of postponement,
with the idea that eventually the symptoms would demonstrate
the case to be one of Pott's disease. If taken in the early stage,
a cure could be effected and the bones would escape implica-
tion.
Dr. J. Cronin, of Buffalo, had seen two or three cases of
psoitis, and said that in diagnosis valuable aid would be found
in putting the patient under the influence of chloroform, flex-
ing the thigh, and searching for fluctuation over the region of
the psoas muscle. A history of traumatism was important in
diagnosticating psoitis. Let the pus escape, he said, then keep
the leg in the extended position, bringing the walls of the sac
together, and union would rapidly take place.
Dr. E. M. Moore, of Rochester, thought that, wThere it could
be shown that the disease had begun with a traumatism, it was
unnecessary to try to explain its occurrence on the supposition
of a tubercular inflammation ; an acute disease might become
chronic, and, of course, when this occurred there was a good
opportunity for tuberculosis to develop. But the commence-
ment might have been in fibrous tissue, and extension have taken
place thence to the bone.
Note on Two Peculiar Conditions of the Mammary
Gland was the title of a paper, by Dr. S. T. Clark, read by
title.
Shock and the Effects of Injuries upon the Nervous Sys-
tem.— Dr. Charles W. Brown opened a discussion on this sub-
ject with a short paper, in which he described the symptoms
Nov. 21, I8t>5.]
PROCEEDINGS OF SOCIETIES.
583
present in shock, and referred briefly to the explanations which
had been suggested of its nature. He had seen a few cases of
what had been termed "insidious" shock, in which the patients
did not suffer pain in proportion to the seriousness of the injury,
and were of a cheerful state of mind, although there was almost
a diagnostic melancholy expression upon the face, which seemed
to foretell death, lie also referred to individual susceptibility,
and said that some persons of fleshy habit and apparent health
would succumb to a minor injury to which some others of deli
cate habit and nervous temperament would give way less readily.
Shock was less marked in persons suffering from chronic dis-
ease, but such persons were less likely to regain strength and
make a complete recovery afterward than those of previous
good health who might be able to withstand the first influence
of the injury upon the nervous system. There were two indi-
cations in treatment : the first, to modify the effects of the shock,
and the second, to control excessive inflammation. The use of
heat and stimulants received some attention.
Dr. Frank H. Hamilton, of New York, continued the dis-
cussion with a short paper, read for him by Dr. Bermingham.
His remarks were limited to surgical shock, which might be
defined as a general paresis of the nervous system induced by
external violence. One point which received his attention was
what was called railroad shock. Many of the symptoms which
had been described as belonging to railroad shock were seen in
certain cases of shock which occurred before railroads had come
into existence. But, if we admitted that the introduction of
railroads had brought into existence a particular kind of shock,
he thought it was due to that sort of injury to the spinal col-
umn which was likely to occur in railroad accidents, resembling
the cracking of the leash of a whip. In these cases he believed
that the injury was not primarily of the nature of a shock re-
sulting from com motion of either peripheral or central nerves,
but that those structures which lay external to the spinal mar-
row and contributed more or less to its support and protection,
of which the ligaments were the chief, were those which suf-
fered direct injury, and from which inflammation subsequently
progressed to the spinal marrow itself. As to the treatment of
shock, reaction should be brought about by rest; in some cases
by warmth, stimulants.
Dr. Edmund S. Arnold continued the discussion with a brief
paper, in which he took the view that shock was due to an im-
pression produced upon the sympathetic nervous system, tend-
ing to stop its function, and, in doing so, stopping nutrition of
vital parts over which that system of nerves presided. Sudden
death would occur if such influence was sufficient to entirely
destroy the function of this system of nerves or ganglia, as in
case of lightning stroke. Another illustration, he thought, was
in death by hydrocyanic acid. If there was an influence upon
the heart in this case, he thought it was directly due to sup-
pressed function of the sympathetic system, which presided
over its action.
Some general discussion took place, Dr. Kneeland, Dr.
French, Dr. Moore, Dr. Arnold, Dr. Van de Warker, and Dr.
Hendricks participating.
Insanity following an Injury of the Head; Cerebral
Cyst; Operation; Recovery.— Dr. Carlos F. McDonald read
a paper with this title, the case being that of a man who re-
ceived a pistol shot in the frontal region, inflicted by his own
band. The man was sent to prison, where he developed symp-
toms of insanity, and had to be confined in a cell. For a con-
siderable period of time, however, he had been required, and
was able, to do prison duty, but manifested a passionate temper.
It was decided to trephine at the seat of the wound, which was
half an inch in diameter, a fourth of an inch in depth, located
over the right first frontal gyrus, corresponding to the junction
of the anterior and middle third, three eighths of an inch to the
right of the median line. The patient was etherized, the wound
was found traversed by dense fibrous tissue, and no bone cov-
ered the dura mater. A fine hypodermic needle was intro-
duced, and nothing was withdrawn until the fourth puncture
was made, when about two drachms of serum were withdrawn.
The fluid contained a few blood- corpuscles, which were acci-
dental. Nothing more was done than to close the wound with
suture and dress it antiseptically. The patient, on coming from
under the influence of the anaesthetic, was in his natural mind,
and was greatly pleased with the relief from pain at the seat of
the injury, and shortly afterward gave a satisfactory account of
his case from the beginning, excepting for a period when he
was unconscious. He went on to complete recovery, with per-
manent relief from cerebral symptoms except for a part of a
day. It was learned that the physician who saw him after the
shooting had removed the pistol-ball; be found no fracture of
the bone and no spiculae.
Discussion on Pneumonia.— Dr. Austin Flint opened the
discussion with a paper in which he propounded the following
questions :
1. Was acute lobar pneumonia a primary local inflammatory
disease, or was it an essential fever, the pulmonary affection
being secondary thereto and constituting its anatomical charac-
teristic?
Since 1877, when he read a paper in support of the doc-
trine that acute lobar pneumonia was not a local affection but
an essential fever, that doctrine had been gaining ground. The
view was supported by the following facts : 1. Acute lobar
pneumonia was characterized by an enormous exudation into
the pulmonary alveoli, and this exudation might be rapidly ab-
sorbed, leaving the tissues intact. This anatomical fact, he
said, had no analogy in local disease. 2. Acute lobar pneumo-
nia never persisted and became a chronic affection. 3. It was
never referable to any appreciable local condition, nor was it
possible by any form of traumatic injury to produce the affec-
tion. 4. Ordinary causes of local disease were not capable of
producing acute lobar pneumonia. The traditional belief that
the affection might be produced by cold was without founda-
tion, and was being abandoned even by the Germans. 5. That
a special or specific influence was invariably the cause of acute
lobar pneumonia was rendered probable by its occurrence at
certain seasons, its greater frequency in certain climates, and
its occurrence at times as an endemic disease. G. It differed
from acute primary local inflammation in that at the outset
there was a pronounced chill. 7. In the course of the disease
the temperature and associated febrile phenomena bore no con-
stant relation to the local affection. 8. Experience showed
that acute lobar pneumonia responded better to treatment ad-
dressed to the fever than to the local affection.
2. What facts and rational grounds, with our present knowl-
edge, could be cited in support of the doctrine that acute lobar
pneumonia depended on the presence of a specific micro-organ-
ism ?
Dr. Flint left this question for discussion to Dr. Janeway,
but expressed his belief in a specific micro-organism as the
cause of the disease.
3. What conditions or circumstances incident to acute lobar
pneumonia tended to render the disease fatal {
The present or previous existence of certain other diseases
rendered the prognosis more unfavorable, and certain condi-
tions, as empyema, pulmonary gangrene, malarial miasm, etc.,
were more likely to develop in one who had been reduced by
pneumonia. But of special conditions, rendering danger of a
fatal issue in the course of the disease greate-t, the author men-
tioned heart-clot and heart-failure.
584
PROCEEDINGS OF SOCIETIES.
|N. Y. Mkd. Jock*,
4. Were there known remedies or therapeutic measures ca-
pable of arresting this disease, or of exerting a curative influ-
ence by either shortening its duration or conducing in any way
to a favorable termination?
Dr. Flint had reason to believe that quinine had been of
benefit in shortening or exerting a favorable influence upon
acute lobar pneumonia. But he could not enter fully into a dis-
cussion of the treatment.
5. Was blood-letting ever indicated in this disease, and, if
so, what were the circumstances indicating and contra-indicat-
ing this measure of treatment?
Acute lobar pneumonia tended intrinsically toward recovery.
Treatment in general should be for special indications. He be-
lieved there were circumstances in which blood-letting would
prove of benefit, and that benefit would be most likely to mani-
fest itself in relief of oppressed heart- action. Contra-indications
to blood-letting were, previous existence of enfeebling affections
and the anasmic state. A plethoric condition and a bounding
pulse were among indications for this measure. The collection
of cases made some years ago by Lewes, in which there were
twenty-eight deaths out of a total of seventy-eight cases in which
blood-letting was resorted to, showed a high mortality ; but the
cases were not selected.
6. Was alcohol useful in the treatment of cases of acute lobar
pneumonia, and, if so, what were the indications for its use,
and how was its use to be regulated as regards the quantity
given, etc. ?
The author regarded alcohol as indicated wherever the sup-
porting plan of treatment was required, wherever there was a
tendency to asthenia. It should be begun tentatively.
7. To what extent was it safe and useful to employ antipy-
retic measures of treatment in cases of acute lobar pneumonia,
inclusive of the cold bath, sponging of the body, or the wet
sheet ?
Dr. Flint spoke specially as to his experience with the wet
sheet, which he had employed in three cases, with favorable re-
sults.
8. Did relapses of acute lobar pneumonia ever occur during
or shortly after convalescence, and did this disease involve any
special liability to other diseases or sequels?
The first part of the question the author answered in the
negative, and said this fact was in favor of the view that the
disease was an essential fever, for local diseases had relapses.
But one attack did not exempt against subsequent attack's.
The first question propounded was discussed in brief papers
by Dr. Didaina and Dr. Ross ; the second by Dr. Janeway, who
expressed regret at having been unable, on account of sickness,
to make further personal investigations regarding the influence
of a micro-organism in the causation of pneumonia. He gave a
synopsis of the literature of the subject. The third question was
discussed by Dr. W. H. Robb and Dr. H. M. Biggs ; the fourth
by Dr. T. F. Rochester and Dr. E. Van de Warker ; the fifth by
Dr. S. T. Clark and Dr. C. S. Wood ; the sixth by Dr. John
Shi ndy and Dr. E. D. Ferguson ; the seventh by Dr. G. Gris-
wold, Dr. C. G. Stockton, aDd Dr. W. S. Fuller ; the eighth by
Dr. J. G. Orton.
(To be concluded.)
MEDICAL SOCIETY OF THE COUNTY OF KINGS.
Meeting of September 15, 1885.
The President, Dr. J. A. McCokkle, in the Chair ;
Dr. Z. T. Emery, Secretary.
Hospital Obstetrics. — Dr. Charles Jewett read a paper
with this title. [See page 565.]
Dr. Stuart remarked that there were several points of spe-
cial interest in the paper, first as to the very excellent remarks
upon the application of the forceps, and the particular refer-
ence as to slow delivery. He had been in the habit, as some
of the members of the society probably remembered, of using
the forceps very frequently, and he had read a paper some years
ago advocating the use of the forceps in delayed labor. He had
modified his views somewhat in that respect, but he had grown
more and more to see the value of what Dr. Jewett had said in
regard to slow delivery when it was compatible with the safety
of the patient. He was glad to know that there was not pre-
vailing at the Long Island Hospital one form of fever which
had prevailed all over the country, and which raged somewhat
fiercely in New York for some time, namely, the fever of
douching the vagina with antiseptic solutions, thus alarming
the patient to a greater or less extent for fear there might
be some germs of disease lurking about to cause her death by
puerperal septicaemia. He was glad to know that the staff of
the hospital did not insist upon that method of treatment.
But it was important to have the forceps always ready, in
case delivery by that means was found to be necessary. Re-
ferring to the treatment of abortion, he thought the reader
might have made more of it. There was no procedure of
more importance to the obstetrician than the clearing of the
uterine cavity thoroughly under such circumstances. Midwives
might attend cases of labor and no harm result therefrom ;
but they could not attend cases of abortion with impunity, and
the very best physician was often at a loss how to proceed.
It would be remembered that, during the first three months of
ntero-gestation, the union between the membranes and the
uterine wall was very intimate. That was necessarily the case
from the anatomical and physiological conditions existing at
that time. It was for that reason, it seemed to him, that the
treatment of abortion was so little understood by so many of
the profession; and those who were in the habit of seeing cases
of neglected abortion were those who were most aware of the fact
that they were not properly treated. On account of this intimate
union between the uterus and the foetal appendages there was dan-
ger of haemorrhage. The physician in attendance was sent for.
perhaps, to find that the ovum had escaped. He found it entire
in the bed, or in the vessel under the bed. He made a hasty ex-
amination of it and its appendages, and concluded that every-
thing was satisfactory. There was no marked haemorrhage at
the time, and he went away feeling that the patient was not
losing more blood than was normal under the circumstances.
He came back day after day, inquired upon that point, and
found that there was more or less haemorrhage. The general
practice of those who attended such cases was to go away and
come again and keep on coming! There were physicians pres-
ent who had had cases come to them from the hands of other
physicians that had been going on for weeks after the ovum had
escaped, the patients having become thoroughly bleached — los-
ing arterial blood all the time. The only way to treat an abor-
tion was that mentioned in the paper — by making a thorough
and complete evacuation of the uterine cavity at the time the
abortion occurred and by the use of the means specified. The
profession was indebted to Dr. Skene, he believed, for the sug-
gestion of the use of Sims's speculum in the performance of
operations in the lying-in room. The use of Sims's speculum
by Dr. Jewett showed its great advantage.
Dr. Palmer had noticed in every case, with the exception
of two or three, that he had attended in his own private prac-
tice and in that of others, that there had been an elevation of
temperature on the second, third, or fourth day, sometimes ac-
companied with a cessation of the lochial discharge, douches
having been abstained from. He attributed this to retrograde
metamorphosis taking place in the uterus, and an absorption of
Nov. 21, 1885.1
PROCEEDINGS
OF SOCIETIES.
585
the effete material. Again, on the third day, about the time of
the establishment of the secretion of milk, he had noticed this
same elevation of temperature, which subsided upon the full
flow of the secretion. In the cases attended by him the douche
had not been used in any way. When there had been a total
disappearance of the lochia, he had simply used hot- water com-
presses over the vulva. In every case there had been a good
recovery. He had seen no septicaemia.
In reply to a question by Dr. Thallon, Dr. Jewett stated
that the strength of the nitrate-of-silver solution used by Credo
was two per cent.
Dr. Chase asked Dr. Jewett's opinion regarding variations
of temperature after labor as evidence of complications. What
was the normal range of temperature in childbed ?
Dr. Jewett referred to certain observations upon this point
by Dr. Napier and by Dr. Macdonald, which had appeared in
the "Edinburgh Medical Journal" within a few years. He be-
lieved, with Napier, that 99'5° F. should be regarded as the
physiological limit during the first four days following labor,
and 99° thereafter. Higher temperatures, while they were more
frequently due to trivial causes, rather than to sepsis, always
demanded investigation. The thermometer afforded the most
important evidence of the patient's condition.
A member asked whether it was Dr. Jewett's practice to use
chloroform in normal parturition. The question had been sug-
gested by the large percentage of lacerations. The use of chlo-
roform he thought helped to prevent perineal injuries.
Dr. Jewett replied that he gave chloroform as a routine prac-
tice during the second stage. He believed humanity demanded
it, and that there was no scientific objection to it. Indeed, there
were scientific considerations in its favor. Many physicians did
not agree with him. They saw bad effects from chloroform ;
inertia during labor and relaxed uterus after labor. He thought
the disadvantages of chloroform insignificant if it was not given
too freely. His method was to allow a few whiffs during the
acme of the pain, often pushing the anaesthesia nearly or quite
to the surgical degree for a few moments as the head passed the
vulva.
Membranous Dysmenorrhcea was the title of a paper read
by Dr. Alexander J. C. Skene. [See page 501.]
Dr. Rochester asked whether Dr. Skene felt as if he really
had seen appreciable benefit from any mode of treatment, or
whether it was a matter of some doubt if the treatment had
had anything to do with it.
Dr. "Skene replied that he thought his histories of cases
covered that ground, but he could answer that question more
fully by stating that for a long time he had been positive that
he did some harm and not, much good by local or general treat-
ment or both, en/ployed on the theory that the trouble was in-
flammatory, and was sure of that point; and the next was that
he did not remember a patient who got well without treatment,
or in spite of treatment. When left alone they generally went
on from bad to worse. There were those that recovered appa-
rently for a time, but there was a recurrence again and again.
Sometimes by a change of location or of circumstances the gen-
eral health would improve and the patient would recover, and
some might remain well. Since he had adopted the treatment
given in his paper a large percentage recovered. Take the case
treated by Dr. Barker, which was only one of a number that
showed the value of the treatment. In conversation he (Dr.
Barker) had told the speaker that he produced much benefit
with the method of treatment which had been advocated in
the paper. Ho had been using it for years. The speaker be-
hoved that by a mode of treatment based on true pathology
much had been accomplished and many cures effected, not alone
by him, but first by Dr. Barker.
Dr. Rochester had had one patient suffering with mem-
branous dysmenorrhcea whom he had treated constitutionally
only, in March last, without applying local treatment. She
afterward married, and had had no dysmenorrhcea since. That
was the reason for his having asked the question.
Dr. Skene asked if the patient had borne children.
Dr. Rochester said she had.
Dr. Skene would say, then, that the doctor did not cure the
patient, but that she was cured by pregnancy.
Dr. Rochester said that that was what he meant to imply.
Dr. Skene did not wish to pass that point so lightly, but
would like to add that patients might recover after having be-
come pregnant.
Dr. Stuart said there was a little confusion in his mind as
to the point of there being ovarian irritation, and the use of
local applications to the uterine cavity. If the trouble was, as
the reader would hold, due to ovarian irritation, he could hardly
understand the philosophy of the local applications to the uterus
except for a diseased condition of the uterus that might exist.
In the two or three cases that he had thought of as Dr. Skene
had been reading his paper, he could not recall them fully
enough to speak of them distinctly, except in one instance, and
that was only a temporary trouble, lasting for but two or three
menstruations. That patient recovered without local treatment.
He was satisfied that this was a case of conception, and that
there was an exfoliation of the decidua vera. This lady had no
uterine disease whatever, and had never had any form of leu-
corrhcea and no disturbance of the menstrual function except
these two or three attacks. Attention was given to her general
health and she recovered. The cast that was thrown off at one
of these periods was a perfect specimen, and would have served
for the original of the reader's description in the paper. He
rose simply to ask the question as to the philosophy of the local
applications.
Dr. Skene looked upon the criticism as a very pertinent
one. He would simply say that, while derangement of nutri-
tion was no doubt produced originally from the ovarian irrita-
tion, the order of pathological events simply followed the or-
dinary rule — that a disease might he caused by some extrinsic
disturbance, and, after the cause was entirely removed, the dis-
ease might continue. To illustrate: We very often observed
mental affections which could honestly be traced to some pelvic
disease ; and yet, the pelvic disease being entirely remedied,
the brain trouble produced thereby continued. We saw the
same thing in some forms of nervous dyspepsia — ovarian dys-
pepsia ; after the removal of ovarian trouble the disease (dys-
pepsia) continued. So he believed that, even after we removed
or quieted the ovarian irritation, this habit of irritation or brain
or gastric disease might, go on ; and that was the occasion for
the local treatment. Recent pathologists had proved that the
investing membrane of the ovaries was exactly like the endo-
metrium, the only difference being that the Graafian follicles
were closed, while the utricular glands were not. (See an ar-
ticle by M. P. Jacobi, M. I)., begun in the January number and
continuing up to this time in the "American Journal of Ob-
stetrics.")
PHILADELPHIA PATHOLOGICAL SOCIETY.
Meeting of October 22, 1885.
The President, Dr. J. C. Wilson, in the Chair ;
Dr. W. E. Hughes, Recorder.
A Comparison of the Changes in Arteries after Ligature
and in the Ductus Arteriosus and Umbilical Arteries after
Birth. — Dr. J. Collins Warren read a paper with this title.
586
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jouh.,
After the ligature of an artery in its* continuity, he said, the
earliest changes noted were the formation of the thrombi within
the vessel, and the development of a mass of inflammatory tissue,
or callus, around the point of ligature externally. No percepti-
ble cell action could be observed in the inner wall with low
powers during the first week, although, under favorable circum-
stances, a proliferation to a limited extent of the endothelial
cells near the point of ligature could be seen with high powers,
and occasionally a few wandering cells might be found to have
penetrated the walls of the vessel at the same point. In the
second week the bundle of fibers of the adventitia which were
surrounded and held by the knot had been absorbed, and the
two ends of the vessel retracted slightly from one another, leav-
ing the ligature imbedded in and partly disintegrated by the
granulation cells. The walls of each portion appeared to form
a complete cul-de-sac, and it looked at this time as if the healing
process were complete, but it could hardly be said to have more
than begun, as the vessel had not yet passed through what
might be considered as the first stage of healing. The begin-
ning of the second stage was marked by an unfolding of the
ends of the vessel, the walls separating somewhat after the
manner of opening of a bud, which permitted the entrance of a
considerable quantity of the granulation tissue. A disintegra-
tion of the thrombus followed, and there were now a fully devel-
oped external and internal callus, a small fragment of clot still
protecting the latter from the current. The ligature might be
totally disintegrated and absorbed, or have become encysted, or,
finally, have created a small abscess about itself which had dis-
charged the fragments of thread through a sinus opening ex-
ternally. The second stage was completed when the internal
growth had reached the neighborhood of a branch. After this
there was an absorption of the callus, which, as in fracture, was
only a provisional structure, and eventually the two ends of the
vessel were found held together by a slender cord of varying
length. The walls of the vessel were slightly separated at each
end by a cicatrix consisting of connective tissue externally, in-
side of which was another layer consisting largely of unstriped
muscular fiber, the surface being covered within by a new endo-
thelium. The cicatrix was always pierced by a vessel, which
terminated in a number of capillaries ramifying in the cord.
Here there was a scar made up of three layers resembling closely
the three coats of the vessel. In the large vessel of an ampu-
tation stump there was a somewhat different series of changes.
Soon after the ligation the end of the vessel might be seen im-
bedded in granulation tissue, and containing a thrombus of
varying length. By the second week there was a marked change
in the intima, extending for some distance above the point of
ligation, probably to the first large branch, or to the origin of
the vessel. Examined several months later, when the healing
process had been completed, the vessel was found to be pre-
served in the form of a cord, running from the first large
branch to the cicatrix of the stump. On laying open this cord
the walls of the vessel were found preserved, the interior being
filled with new tissue, leaving spaces occupied by one or more
vessels. There had been a process resembling that known as
obliterating endarteritis, by which the caliber of the blood-
channel had been narrowed to an extent to adapt it to the
diminished blood-supply. In this obliterating tissue we found
comparatively large vessels, with new coats consisting of an
endothelium, an elastic membrane, and also a new media. An
erosion preparation would best represent the condition of the
arteries of the stump at this time. The main artery would,
after giving off its largest branches, break into a spray of smaller
vessels, no one of which would predominate. A comparison
of these two modes of healing with the changes seen in the
arterial system after birth showed certain resemblances iu the
two processes. The ductus arteriosus, about the time of birth,
differed considerably from the structure of the aorta and the
pulmonary artery. The media was much thicker than in either
of these vessels; it was thrown into irregular folds, which were
increased at the time of birth and helped to narrow its caliber.
The distinctions between the different layers of its wall were
less marked than in other vessels. The lamina elastica was in-
distinct and in places apparently wanting; the media consisted
chiefly of longitudinal layers of muscular fibers, a few circular
bundles existing in the innermost layer. A few weeks after
biith a greater portion of the walls of the ductus underwent
hyaline degeneration, the inner or circular fibers of the media
alone remaining, these being re-enforced apparently by a growth
from the media of the larger vessels. At this time there was
an active growth of long spindle-shaped cells with staff-shaped
nuclei at the edges of the media bordering on the opening into
the aorta; here was also a moderate thickening of the intima.
Eventually the hyaline tissue became absorbed, and was replaced
by a ligamentous band of fibers, which became continuous at
either end with the media of the larger vessels. At the aortic
end, in a longitudinal section, we saw the media slightly sepa-
rated. At the point of tbe cicatrix, and between them and also
continuous with them, were the longitudinal fibers of the liga-
mentum arteriosutn. In this ligamentous tissue, and between
the edges of the media, were numerous new muscular cells;
nearer the surface there was a layer of thickened intima, which
in the aorta had not only connective tissue in it, but also a
deep musculo-elastic layer; in tbe center of the depression
marking the site of the cicatrix a small vessel was given off,
which penetrated into the axis of the ligament, where it either
lost itself in a capillary network, or became continuous with a
similar vessel coming from the pulmonary artery. These con-
ditions closely resembled those which had been described as
existing in the cicatrix of a large artery, after ligature, in its
continuity — namely, the slightly separated ends of the media,
between which lay the fibers of the ligament connecting it with
the pulmonary artery, a new intima and a new growth of mus-
cular cells, and finally a central arteriole. The only point of
difference was the preservation of a layer of circular muscular
fibers, which formed an outer wall to the ligamentous band, a
much-needed support at a point exposed to gre:it tension. Fur-
ther protection was afforded by the oblique insertion of the
ductus into the aorta, diminishing the pressure upon this par-
ticular point. At birth the umbilical artery, or that usually
called the hypogastric artery, the portion within the abdomen,
at its origin from the internal iliac, was a vessel of considerable
size, being, in fact, a continuation of that artery. At its termi-
nation in the umbilical wound it had greatly contracted and
was tilled with clot for a distance of about one inch. The out-
lines of the various walls were not so distinct as in other ves-
sels, and the elastic lamina for the most part was wanting. No
special change was seen in the elements of the walls of the ves-
■ sel except a slight accumulation of endothelial cells near the
apex of the thrombus. A few weeks later there was a distinct
growth on the inner surface of the wall up to its point of origin,
the terminal portion having undergone a hyaline degeneration
and obliteration for a short distance. The vessel had greatly
contracted throughout its entire length, and its caliber was fur-
ther diminished by the growth in its interior. Cross-sections
taken from the superior vesical artery in adult life showed the
media as a wall thick out of all proportion to the size of the
vessel, and consisting not only of its original wall, containing
longitudinal muscular cells interspersed with elastic tissue, but
also of an inner circular row of cells which was provided with a
well-formed elastic lamina. It seemed probable that the greater
portion of the hypogastric artery had been preserved, the liga-
Nov. 21, 1885.]
PROCEEDINGS OF SOCIETIES.
587
mentous band, which extended to the umbilicus, consisting of
the obliterated extremity of that vessel, much elongated during
the process of growth. The series of changes which occurred
in the hypogastric artery after birth was closely analogous to
that seen in the main trunk of an amputation-stump — a slight
portion of each vessel was destroyed ; both retracted and were
attached to the terminal cicatrix by a band of fibrous tissue;
both remained as pervious vessels, with thickened coats and
narrowed caliber. In both the process was not unlike that seen
in the so-called obliterating or compensatory arteritis. Arteri-
tis hardly seemed a term applicable to the changes taking place
in normal arteries after birth, nor could the alterations which
had been developed through the whole length of a large vessel,
extending a considerable distance from the original seat of in-
flammation, be strictly regarded as of an inflammatory nature.
Might not the obliterating growths found to exist simultaneous-
ly in terminal arteries in widely remote portions of the body of
the same individual also be regarded, not as of an inflamma-
tory nature, but rather as a secondary and formative process,
closely connected with disturbances in the mechanism of nu-
trition, designed to adapt the vessels to a diminished blood-
supply ?
Dr. S. W. Gross said that, in view of the fact that Dr. War-
ren's teaching seemed so directly opposed to that of other ob-
servers, he would like to have some points cleared up. He
would, therefore, ask if Dr. Warren held, first, that, instead of the
external coat, where it was included in the ligature, sloughing
and coming away with the ligature, the pressure of the ligature
set up an irritation which caused the adventitia to return to its
embryonic state with a reconversion, after the ligature had cut
through this, to connective tissue ; and, second, whether the repair
of arteries was brought about by the ingrowth of the cicatricial
tissue, which he likened to provisional callus, together with
some proliferation of the muscular cells of the media.
Dr. Randall said that, as the result of careful study of the
subject, he had always found the clot present at first, and that
it was honey-combed even in the first few days by the contrac-
tion of its fibrin ; through the spaces thus formed the blood
seemed to be circulating. Cells, either original white cells or
of endothelial origin, occupied the walls of these cavernous
spaces and seemed to sheathe them. The red cells early melted
down into a homogeneous mass, furnishing the frame-work upon
which the reparative tissue was built. The '' plastic-clot " of
some observers he had not seen — the new cells being distributed
throughout the old clot as well as upon the vessel-walls, and not
specially collected in the immediate neighborhood of the ligature.
The obliteration of the vessel was accomplished by the growth
and contraction of the trabecules of new tissue built upon the
remains of the original blood-clot. Even close to the ligature
he had not found the vessel-walls greatly altered, merely show-
ing a great increase in the nuclei and in the number and size of
the vasa vasorum, the lamina elastica being distinct and, as a
rule, intact. Toward the end of the first month the new tissue
consisted largely of spindle-cells, but careful staining had given
no suggestion of muscular tissue. But, not having carried his
study beyond the first month, he had no data upon this subject,
since the development of muscular tissue was asserted to occur
only at a later stage.
Dr. Form ad was inclined to favor the views of Dr. Randall.
The observation of Dr. Warren that the new-formed connective
tissue played the most important part was to him entirely novel.
He thought that probably pressure upon the artery from with-
out, with consequent diminution in its lumen, might bring about
a condition more analogous to the growth of foetal life than to
inflammation.
Dr. Meaks remarked that we were liable to be confused in
considering this subject by the presence of the blood in the ves-
sel. So far as the process of healing after ligature was con-
cerned, we might consider only the structures which entered
into the formation of the vessel-wall, which was complex in
character and composed of connective, yellow elastic, and endo-
thelial tissues. Dr. Warren had given a very clear demonstra-
tion of cicatrization as it occurred in these structures after appli-
cation of the ligature.
Dr. Tyson said the most novel feature, to him, in Dr. War-
ren's observations was the part played by the muscular tissue.
This apparent increase in the muscular tissue he was inclined to
believe was really only a proliferation of inter- muscular connect-
ive tissue. He was becoming more and more convinced that there
was only one kind of inflammation — the interstitial. He feared
that he might himself mistake a proliferating connective tissue
with spindle cells for muscular tissue. It was true that new-
formed capillaries and arterioles had muscular walls, but the de-
velopment of these seemed to him to be a slower process. He
had expected to find a process of repair in the ductus arterio-
sus different from that in an ordinary artery. This process he
had expected would be a true endarteritis, for it seemed that
the conditions of closure here were rather different from those
in the ligaturing of an ordinary artery and in the umbilical ar-
tery, where also ligation was practiced.
Dr. Warren, in closing, said that, in cases where there was
much breaking down, with little repair, there might be a slough-
ing of the externa] coat, yet in his experiments this part of the
arterial wall had not sloughed, but had simply been absorbed
by the granulation tissue, as the ligature itself was in some cases.
In the normal condition even the elastic lamina was not a per-
fectly continuous plate; he did not refer to these breaks, how-
ever, but to numbers of little ruptures incident to the pulling
of an artery out of the wound in the act of ligation ; however,
this need not necessarily occur. He had not attempted to iden-
tify anything like muscular tissue early ; this could not. be rec-
ognized till a permanent cicatrix had been formed. He had
carefully eliminated all sources of error, and it seemed to him
that in almost all cases there was a considerable number of
these muscular cells. The layer was not always so well marked
as in his diagrams; especially was this true of human specimens,
but these had all been in alcohol for some years; of the fresh
specimens he had selected only those in which he had consid-
ered the process complete. In a specimen which he had with
him, through an opening in the lamina elastica cells could be
traced from the muscular layer, those in the inside resembling
exactly those outside. These facts, together with the fact that
normally there were a few nlnscular cells inside of the lamina
elastica, led him to believe in the proliferation of the muscular
tissue. The disintegration of the blood-clot was accomplished
by granulations growing inward from the callus, there being
two sets of blood-vessels — one in the granulations, the other
(blood-spaces, rather) in the clot itself. These united about the
end of the first or second month.
BROOKLYN PATHOLOGICAL SOCIETY.
Meeting of September 2^, 1885.
The President, Dr. B. F. Westbrook, in the Chair;
Dr. A. H. P. Leuf, Secretary.
(Edema of the Glottis ; Tracheotomy ; Death.— Dr. J. C.
Bowker read the history of the case, in behalf of Dr. 0. A.
(Jordon, who was absent.
"Thomas T., aged fifty, a laborer, strong and well nourished
applied for admission to St. Mary's Hospital, September 2d, at
about 5 p. m. He said he had suffered from a sore throat for
5>S
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jour.,
about a week and had been unable to swallow much solid food
for two days. He was quite hoarse, and unable to open bis
mouth more than three fourths of an inch, making an examina-
tion of the larynx very difficult. There was quite a marked en-
largement in the left submaxillary region. The temperature
and pulse were about normal. He was sent to the ward and an
external application of iodine was made. When I made the
evening rounds the patient was walking about the ward in con-
versation with other patients. I advised him to go to bed, in-
tending to make a more careful examination in the morning.
At about 8.30 the same evening the orderly rushed into my
room and said the patient was choking. I hastened to the ward
and found him gasping for breath and very cyanotic. I tried
to pass my finger into his larynx. Failing in that, I opened the
trachea at once without dissection and dilated the opening with
a forceps until the tube was inserted. Although the operation
was done as quickly as possible, the man had ceased to breathe
before its completion, and persistent efforts at artificial respira-
tion failed to revive bim.
" The autopsy, made by Dr. Leuf, the pathologist, revealed
marked oedema of the glottis, the whole mucous membrane
above the vocal bands being involved. There was quite a large
abscess situated in the left tonsillar region. The heart was filled
with venous blood, and the lungs were emphysematous. There
was cerebral oedema. The other organs were found to be
normal."
Dr. Wackerhagen asked if there had been any haemor-
rhage.
Dr. Read wished to know the cause of death.
Dr. Bowker replied that death had resulted from asphyxia.
Dr. Leuf stated that he had found no blood in the trachea
or bronchi.
The President desired to learn if there bad been any brain
symptoms.
Dr. Bowker answered that there had not been, and that
the patient had been in the hospital only a few hours when he
died.
Dr. Bcrge called attention to the difficulty of examining the
throat, from fixation of the jaw on account of the swelling in
the tonsillar region.
Strangulated Femoral Hernia in the Male.— Dr. A. H. P.
Leuf presented a specimen that be had removed from the left side.
The constricting ring was about D25 ctm. in diameter and adher-
ent to the gut passing through it. About 8 ctm. of the ileum
had passed the ring, remaining incarcerated behind the saphenous
opening. The patient had been sick seven or eight days. His
trouble began with obstipation. At first there was no pain, but
afterward he complained of pain in the epigastrium, close to the
ensiform cartilage. Cathartics and enemata were given, and
subsequently he was dosed with opium to relieve pain. At no
time did he have any uneasiness below the umbilicus. Intes-
tinal obstruction was diagnosticated by the attending physician,
Dr. Irish, and both groins were examined several times. The
patient always made contemptuous objections to these investi-
gations, because he referred all his trouble elsewhere and con-
sidered the doctor fanciful. Dr. Watt was called in consulta-
tion, confirmed the diagnosis, and recommended a continuance
of the plan of treatment already adopted. Abdominal incision
was not deemed advisable. There was considerable vomiting,
and death was due to asthenia. There was no sign of peritoni-
tis at the autopsy except a very few vascular injections of the
peritonaeum in the neighborhood of the ring. The extended gut
was darker in color than the remainder, but by no means gan-
grenous. All the adhesions at the femoral opening were recent
n d easily broken down.
Dr. Leuf opened the discussion by stating that the attend-
ing physicians, bad they operated, would have made the ex-
ploratory incision above the umbilicus, near the seat of pain,
and he desired to know the opinion of those present about the
advisability of extending the cut down to the seat of trouble, or
whether it would be better to pass the hand down and free the
gut by manipulating it bimauually — i.e., pulling with the inner
band and pushing with the other.
Dr. Wallace thought that that would depend entirely upon
the surgeon.
Dr. Wackeriiagen said he would always make an ex-
ploratory incision below the umbilicus, regardless of the seat
of pain.
The General Pathology of Fever. — Dr. Joseph Meezbaoh
read a paper with this title. (See page 509.)
Dr. Eccles could scarcely agree with the essayist in the state-
ment that mental work had but little effect upon bodily tem-
perature. Ordinary thinking might show a meager effect, but
intense mental excitement would cause marked elevation. In con-
ditions of terror or apprehension, when there was a tornado of
thought, it was no unusual thing for the person affected to break
out in profuse perspiration. Elevated temperature meant in-
creased oxidation or diminished radiation. A check of perspira-
tion might give rise to elevation of temperature. The act of
perspiring did not lower temperature. It was work done in
evaporation at the expense of bodily heat. Conduction also
aided in keeping down temperature. The irritating presence of
non-excreted waste products might constitute a factor in causing
fever. In most febrile conditions there was a sort of diffuse
inflammation in which the whole system took part. Apart from
the action of specific heat centers, or even without nerve con-
trol, every cell might become an independent heat-producer.
To the physiological psychologist attention was the subjective side
of co-ordinating force, and might be expected to have some bear-
ing upon a subject of this kind. When attention was turned
upon the feeling that arose from any particular organ there were
congestion and increased heat of that organ. A boy at play
might forget that he had a stomach until he thought of food,
when all of a sudden he became hungry. This was true of every
function having a special sensation connected with it. A soldier
might be severely wounded and the injured part bleed but
slightly while terror and duty commanded bis attention, but, so
soon as these ceased and he considered the pain, profuse hasmor-
rhage would set in. The pain was the subjective side of the
wound. Attention turned upon the pain meant that the highest
nervous control of the body discharged its energy toward the
source of that pain. Din-ease was a disturbance of our feeling
of well-being. The concentration of attention during health
upon this feeling maintained it. When much of our body or the
whole body became irritated from any cause, energy went forth
to every disturbed part from the highest centers. Along the
path whence the discomfort came the return-current would go
as soon as attention was turned thither. Thus every heat-pro-
ducing part might be released and a sort of physiological anarchy
ensue. The essayist bad made no reference to the reduction and
elevation of temperature by therapeutic agents, a phase of the
subject well worth considering. Antipyrine lowered tempera-
ture and the salicylates elevated it. Many other agents acted in
one or other of these two ways.
Dr. Leuf had frequently noticed upon himself the effect of
excitement due to overwork in causing a feverish feeling. He
had never measured his temperature with a thermometer, but
could give an idea of the increase of his bodily heat by stating
that he had again and again taken seven to ten, or even more,
goblets of ice- water during an evening, and all within two hours
(from 9 till 11); and during this time he would suffer with throb-
bing of the temples, tension of the head and face, sometimes
Nov. 21, 1885.)
PROCEEDINGS OF SOCIETIES.
589
tinnitus aurium, a dry, parched tongue and lips — in fact, the
tongue sometimes being actually painful. These symptoms in-
variably followed concentrated and continued mental effort.
Still he could not imagine with Dr. Eccles that mental concen-
tration would account for all rises of bodily temperature, if only
for the reason that so many imbeciles, idiots, and children had
fever. In cholera, for instance, there was the greatest mental
apathy, and yet a marked rise in the body-heat. The increased
work done by the body in perspiring could not be adduced as a
general explanation of the reduction of high temperatures, for
there was in some conditions a very high degree of fever, with
profuse perspiration, continuing for days. Oiling the body also
lowered the temperature when it was above the normal, but not
in all cases. There was a reduction resulting from a cutaneous
application and without resulting evaporation. He would also
object to calling a fever a " diffuse inflammation in which the
whole system took part," because that would be impossible with
the present use of the word inflammation. He agreed with the
reader fully in the thought he had intended to express, but ob-
jected to the words used.
Dr. Eooles replied that while children or idiots might not
be able to do any complex thinking, they were subjects of terror
and endurers of pain. On these simple sensations they could
center their attention with considerable persistence.
The President asked if Dr. Leuf had ever reduced excessive
temperature by oiling the skin ?
Dr. Ledf rejoined that he had, and that too when the effi-
cacy of the method could hardly be questioned. In these in-
stances it had been employed either without the use of drugs or
conjoined with placebos. He also replied to a previous question
by the president, that he believed the efficacy of oiling was due
to its lessening heat-production. This, it seemed to him, it did
in two ways. It quieted the nervous system, like the chloral
Dr. Kead used in his cases ; and it relieved the intense irrita-
bility and dryness of the skin by making it soft and pliable, and
avoiding a great deal of friction. He believed that the one great
ever-essential factor in increased beat-production was a certain
disturbance or varying set of disturbances in the visceral sympa-
thetics, especially those of the abdomen. Here were located the
centers of heat, and they generated this in superabundance in
proportion as they increased their activity. Their activity was
presided over and depended upon the visceral sympathetic. As
everybody knew, the thoracico-abdominal sympathetic ganglia
were connected with the outer skin by means of their numerous
double connections with the spinal nerves. It seemed, then, that
oiling the skin also allayed irritability of these ganglionic centers,
causing them to act with more control in regulating the work of
the trunk viscera — the heat centers.
Dr. J. D. Sullivan stated it as his belief that fever was a
disturbance of nutrition due to the nervous system. The waste
in fever must be due to an arrest of nutrition. He put the
question, whether the delirium in fever was the result of in-
creased heat, of a poison, of an arrest of nutrition, or of a con-
dition of the brain. He believed it was caused by changed
conditions of the brain. He then illustrated by citing instances
from his personal experience, when during an attack of fever
he had imagined occurrences which to this day seemed to him
as real as anything he knew, so that he had only become con-
vinced of his mistake upon the positive assurance from relia-
ble sources that he was wrong.
Dr. Ecoles replied that he could take no mental grip upon
the words of the last speaker. To say that defective nutrition
caused fever gave no idea of the modus operandi. If it could be
shown that this defect in any way increased oxidation or re-
tarded the elimination of heat already produced, it would bo an
acceptable hypothesis. As to the delirium of fever, a few sim-
ple experiments, such as he had tried, would cast much light
upon its genesis. During the time our attention was centered
upon the delightful feeling of comfort experienced when about
to drop into sleep, if we divided that attention, delirium of a
mild type might be produced artificially and studied by intro-
spection. "Try to catch yourself going to sleep," he said, "and
an alter ego will arise with whom most incongruous conversa-
tions may occur, and ideas quite foreign to the purely waking
state will intrude themselves. While you are yet awake, absurd
dreams will come up in your consciousness, and you will be
quite aware of their absurdity. It is the result of divided atten-
tion— unconscious cerebration in this way pushes itself within
the door of consciousness." Even in our waking state it often
happened that we did and said irrational things if our attention
was divided. The unfortunate occurrence that had happened
to Mr. Am Ende, the Hoboken apothecary, in which morphine
was substituted for quinine, was probably one of those quasi-
delirious acts of a man with divided attention. It would not
have been beyond possibility for such a thing to occur, and he
know that a blunder was being committed, and yet feel power-
less to arrest it. In the delirium of fever, currents of discomfort
reached the highest nerve-centers from every direction. All
these were subjectively perceived and the attention was dis-
tracted among them. Active cerebration resulted from them in
the most disorderly manner. Attention allowed this chaos to
intrude on consciousness.
Dr. Sullivan rejoined that, if it was possible to explain nu-
trition by chemical or philosophical means, he might be able to
explain how its arrest caused fever.
The President remarked that Dr. Eccles and Dr. Sullivan
viewed the question regarding temperature elevation from op-
posite standpoints. The former looked at it as a physicist, the
latter as a vitalist.
Dr. II. N. Read would speak only on the influence of the
nervous system on the temperature of ephemeral fevers in chil-
dren. He had one case in mind that had shown this beauti-
fully. A young infant suddenly became ill. There were no
other disturbances than those common to fever. The tempera-
ture was 103° or 104° F. He gave chloral to control excessive
irritability and the convulsions — i. e., to reduce the nervous ten-
sion. After several hours the child was in a normal condition.
Such cases were quite frequently met with, and the patients
were wrell within from six to twenty-four hours after the ad-
ministration of a nervous sedative. Often there was not even
constipation. He believed that, if the proper apparatus was
at hand to weigh these children before and after the attack,
there would be found a diminution of weight from superoxi-
dation. He thought that in these cases the fever was brought
about by a change in metabolism due to insufficient nervous
control.
Dr. Leuf remarked that the softening of viscera accompany-
ing fever was of interest and worthy of consideration. He had
noticed that the softening did not necessarily depend upon the
length or severity of the fever. He had not examined these
organs very often with the microscope, but they always had a
fatty appearance. He thought the change in consistence was
due to fatty infiltrations and degenerations, because they were
always soft, pale, and greasy. In his experience, the heart had
seemed most frequently affected, and alter that the kidneys and
liver. The kidneys were often so soft that they could easily be
doubled over ami made to touch end to end, and ibis too with-
out cracking or Assuring, while the capsule was off. When the
spleen was in that condition, it was very mushy and bad a dirty
pale-gray color. The capsule was, as a rule, wrinkled. The
pancreas was also quite often in a similar condition, and, when
so soft, had almost the same grayish color, but with a slightly
590
MIS GEL LA S Y.
[N. Y. Med. J6i<b.,
yellowish tinge. He had simply expressed himself on this point
because there were many who did not consider these changes
fatty, and who denied that fever was the causative agent.
Dr. Merzbach said, in answer to some of Dr. Eccles's re-
marks, that, as regarded the function of the skin, he had stated
in his paper that it reduced the temperature in several ways,
the most important of which was evaporation, then conduction,
etc. The theory which gave the mind so much importance in
the increase of body-heat he did not credit much. He had also
seen very severe haemorrhage from patients during anaesthesia
and in other unconscious conditions, and supposed that every-
body else had also. He could not see how arrest of nutrition
would cause fever, but it certainly was a concomitant. It was
well established that the nitrogenous elements were burned in
greater proportions than other tissue elements were, as was
shown in the increased amounts of urea passed through the
kidneys. All of this waste was not accounted for by the burn-
ing of nitrogenous substances alone, as observation showed
seven per cent, of the total decrease in twenty-four hours not
accounted for. Thus the changes in the urine did not represent
all the destruction. The cause of delirium might be indicated
by the increased amount of phosphoric acid found in the urine.
A similar condition was observed in chronic cerebral irritation
or neuralgia. He did not think it necessary to suppose some
foreign influence to be the cause of delirium. Hot blood might
be sufficient cause. There was, for instance, a chronic excita-
bility noticeable in peoples existing in hot climates. We all
knew the excitability of the races of the tropics, whether civil-
ized or uncivilized, and he supposed it was possibly due to the
continuous irritation of the superheated atmosphere and its
effects transmitted for ages from generation to generation.
The President said it was interesting that in fevers of the
same height there was a great difference as to the amount or
even presence of delirium — for instance, malarial and typhus
fevers. Then the existence of heat-centers was of interest.
Dr. Ott had recently shown quite positively that there was a
beat-center just anterior to the caudate nucleus. Fever, too,
was very often accompanied for days with profuse sweating,
although the temperature remained very high.
Dr. Eccles asked how high the president had noticed the
temperature uuder these conditions.
The President replied that he had seen the thermometer
register 106° F. during continuous profuse perspiration, and
just after marked sweating in typhoid fever he had seen it
104° ; likewise in tuberculosis.
Dr. Merzbach, in closing the discussion, stated that he had
alluded in his paper to the fact that high temperature alone did
not always explain delirium, because in different fevers, as had
already been stated, when the body-heat was the same, there
was a great difference in the degree of delirium. He had not
attempted to explain it, because it could not be done. The only
way in which he could account for persistent high temperature
during perspiration was by supposing the heat-production to be
so great that the sweating could not wholly counteract it.
The Cholera in Spain. — The "Gibraltar ChronWe " publishes the
following: "From a letter," says the 'Times,' "which has just been
published in a Swiss paper, written by the wife of a Swiss merchant
settled in Spain, besides giving a vivid idea of the condition of that un-
fortunate country, shows how much medical men and Government offi-
cers have to contend with in their efforts to combat with the plague that
is working such terrible havoc throughout the Peninsula :
" ' The other day there died in a house not far from ours a widow,
the mother of two daughters. She had been suffering for a long time
from an affection of the chest, and, shortly before her death, a doctor
was called in, who prescribed medicine and gave such directions for her
treatment as he thought necessary. This was on a Saturday night, and
on the following morning the poor woman breathed- her last. No
sooner was this known than a rumor went about that the medicine pre-
scribed by the doctor contained poison, and was given to the widow in
order that she might appear to have died of cholera. The elder daugh-
ter ran into the street like a maniac, shrieking " Scoundrel ! scoundrel !
where is the wretch who has poisoned my mother?" That-was a ter-
rible day for me, especially as Karl (the writer's husband) was not here.
A great crowd gathered before the house of the dead and ours calling
for the judge, and threatening the doctor with death. Then the body
was taken into the churchyard in order that it might be opened. Just
think ; some of the people (as was afterward proved) killed a rabbit
and said it had died after being given some of the physic prescribed
for the widow. After the body was removed there came the judge, and
also the druggist who had mixed the medicine, and, to show how harm-
less it was, the druggist took at a draught all the physic left in the bot-
tle. The doctor also testified that it contained nothing whatever of a
hurtful nature, and was really no more than a refreshing drink. When
the widow's body was opened, moreover, it presented no choleraic symp-
toms whatever, but the lungs were very much diseased, and the cause
of death was proved beyond dispute to be consumption. The excite-
ment and uproar were, however, something terrible, particularly among
the lower orders ; they persisted in believing that the woman had been
poisoned, and paraded the streets, declaring that they would force all
the doctors to drink their own physic ; and most of the patients of Dr.
Antonio Espinosa (who prescribed for the widow) have thrown his
medicine away, and he is bringing an action against the daughters for
defamation of character. In the meanwhile the authorities have recom-
mended the doctors to prescribe only pills, the popular belief being
that pills can not be poisoned. This will give you some idea of what
the people here are like.' "
A Dispensary Service for Mental Diseases. — The establishment of a
service of this sort in Philadelphia, believed to be the first in this coun-
try, is thus announced by the Philadelphia " Evening Bulletin " :
" At the last meeting of the managers of the Pennsylvania Hospital
it was determined to add to the Out-Patient or Dispensary Department
a new service for the benefit of the indigent poor who are suffering
from the early symptoms of insanity, or insanity in its incipient stages.
The managers have 'been led to create this addition to their already
comprehensive service by the conviction that many persons in indigent
circumstances do not receive that advice and medical treatment at a
critical period when experience shows the greatest benefit from treat-
ment may be expected. It is their observation, and that of all connect-
ed with hospitals for the insane, that, in consequence of delay from
various causes, an undue proportion of cases lapse into a chronic and
incurable condition, and in that state are brought to the hospitals.
"Public announcement is therefore made that the managers of the
hospital have made arrangements for the commencement of the new
service on Monday next, November 2d, at 3 p. m., in the Out-Patient
Department, Spruce Street near Ninth, at which hour a physician will
be in attendance. A physician will attend every succeeding Friday and
Monday at the same hour and place until further notice. Chronic cases,
and those requiring custodial care, will not, for obvious reasons, be re-
ceived. The medical service will at first be rendered by the physicians
connected with the Department for the Insane of the Pennsylvania
Hospital. The work which is now proposed is of an experimental
nature, and no conjecture can be formed as to the extent of the de-
mand, nor whether any demand exists which will warrant the perma-
nent establishment of a special department. If no demand for the
additional service that has been provided shall, after a fair trial, be
found to exist, it will be abandoned. But, if it shall appear, on the
other hand, that such a department is likely to prove a great benefit to
the class for which it is designed, some valuable experience may be
Nov. 21, 1885. J
MISCELLANY.
591
derived which may be suggestive hereafter. Every means for the pre-
vention of insanity, or in the direction of a preventive measure, deserves
most favorable consideration. If the measure shall appear to be a suc-
cess, its friends anticipate that it may lead the way to enlarged opera-
tions in the same direction."
The Journal of Heredity is the title of a new periodical, published
in Chicago, and edited by Mary Weeks Burnett, M. D., who modestly
states at the outset that the journal does not " hope to solve all prob-
lems in heredity."
The Massachusetts Veterinary Association lately held its first
meeting, says the "Boston Medical and Surgical Journal," and elected
as officers Dr. Frank S. Billings, of the New York Polyclinic, president ;
Dr. L. H. Howard, of Boston, secretary and treasurer ; and Dr. W. Dry-
den, Dr. W. T. Simmons, and Dr. J. M. Skally, all of Boston, members
of the executive committee. The president read a paper on tubercu-
losis.
Luminous Signs for Doctors. — Speaking of an advertisement of
these contrivances, the " Boston Medical and Surgical Journal " says :
" A< a rule, it is where the 'inward and spiritual grace' least abounds
that there is the greatest ostentation of the 'outward and visible
sign.' "
The Rex Disinfectant. — This is a preparation which acts by the
slow disengagement of chlorine. It is the invention of an Ohio physi-
cian, and should not be confounded with the preservative solution
termed " Rex Magnus." It consists of an earthy-looking, inodorous
powder, to which commercial sulphuric acid is to be added. Chlorine
fumes are at once to be recognized by the odor of the gas and by the
ammonia test, but they are given off so slowly that, while efficient for
purposes of disinfection, they do not render the air of the room irritat-
ing to the air-passages. Speaking from considerable experience, we
have no hesitation in saying that the preparation is an excellent one for
the purposes for which it is intended.
The New York Academy of Medicine. — The next meeting of the
Section in Obstetrics and Diseases of Women and Children will be held
on Wednesday evening, the 25th inst., instead of Thursday, the 26th,
as Thanksgiving Day is appointed for the latter date. Dr. Joseph E.
Winters will read a paper on " Diphtheria and its Management," which
will be followed by a general discussion of the question " Are Diph-
theria and Membranous Croup Distinct Diseases ? "
Pasteur's Preventive Inoculation of Hydrophobia. — The Paris cor-
respondent of the " Medical Times and Gazette," of London, states that
M. Pasteur now adopts the following method. A rabbit is inoculated
with a fragment of the spinal cord of a mad dog. The animal is affected
with hydrophobia in the space of about a fortnight. A portion of its
spinal cord is employed to inoculate a second rabbit, which also con-
tracts the disease, but more rapidly ; the spinal cord of this second rab-
bit serves to inoculate a third, and so on. It is observed that at each
step of this process the intensity of the disease becomes greater, and
the period of incubation shorter. When the spinal cord of these ani-
mals which have died of hydrophobia is suspended in a perfectly dry
tube, its virulence diminishes by degrees, and at last disappears. A col-
lection of these spinal cords, some of them entirely stale and powerless,
others more fresh and active, others again quite fresh and extremely
active, are always kept in readiuess. To render a dog insusceptible of
rabies, he is first inoculated with the stale and powerless specimens, then
with fresher and more active ones, and lastly with the most powerful of
all, when he becomes quite proof against the inoculation of rabies.
Lately, a young boy, nine year3 of age, Joseph Meister, was brought by
his friends to M. Pasteur's laboratory. He had been most severely
lacerated by a mad dog, having fourteen bites in different parts of his
body. M. Pasteur, in presence of the almost absolute certainty of death,
inoculated the child according to his system ; the first inoculation was
made with a spinal cord fifteen days old on the 6th of July, sixty hours
after the child had been bitten. Similar inoculations with virus of con-
stantly increasing intensity were made up to the 16th of July, when the
spinal cord employed was quite fresh. The child, having up to the pres-
ent time, four months after the accident, exhibited no symptoms' of
hydrophobia, is considered by M. Pasteur as radically cured, and he has
already recommenced the same method of treatment upon a young shep-
herd, who, in defending other boys, was cruelly bitten by a mad dog,
which he killed upon the spot. The results of this new experiment will
be communicated by M. Pasteur in due time to the Academy. With
respect to the first patient, the writer remarks, it must be remembered
— (1) That sixty per cent, of people bitten by mad dogs do not contract
hydrophobia. (2) That the incubation of the disease is sometimes ex-
tremely long (cases have been known to occur two years after the bite).
The experiment is not therefore absolutely conclusive, although it marks
a great progress in the history of the disease and justifies in some meas-
ure the enthusiastic applause with which the communication was re-
ceived.
The New Nomenclature of Diseases. — Referring to Circular dated
July, 1874, adopting the Provisional Nomenclature of Diseases of the
Royal College of Physicians of London as the official nomenclature of
diseases, and to paragraph 310 of the Revised Regulations of 1885, the
surgeon general of the Marine-Hospital Service, under date of Novem-
ber 7, 1885, informs the medical officers of the service that the revised
edition of 1885 of said Nomenclature will be used on and after Janu-
ary 1, 1886, instead of former editions.
The Late Dr. Samuel G. Armor.— At a recent meeting of the De-
troit Academy of Medicine the following memorial resolutions were
adopted :
Whereas, It has been announced that Professor Samuel G. Armor,
M. D., LL. D., an honorary member of this body, and for many years a
resident of Detroit, died at his home in Brooklyn, N. Y., on the 27th
ultimo, in the prime, of his vigor and usefulness,
Resolved, That, while we bow in submission to the decree of Infinite
Wisdom, yet we hereby express our sense of sore bereavement in his
death.
Resolved, That the untiring devotion which our friend had exhibited
in his chosen life-work, the large-hearted generosity which he uniformly
manifested toward his brother physicians, and the delicate sense of
honor that marked all his dealings with them, together with his thor-
ough integrity and broad manhood, endeared him to the majority of our
membership personally in life, and remain enshrined as his best legacy
in death.
Resolved, That we extend our warmest sympathy to the great num-
ber who, in the death of Dr. Armor, mourn the loss of a friend and
teacher.
Resolved, That a copy of these resolutions be sent to the family of
Dr. Armor, to the Long Island College Hospital faculty, to the several
medical journals of Detroit, and to the New York " Medical Record "
and the " New York Medical Journal."
Edward W. Jenks,
(Signed) George P. Andrews,
J. F. Notes,
Committee.
Dr. Kinloch on the Congress. — In a letter to the editor of the
"Medical News," of Philadelphia, a member of the committee from
South Carolina says :
"My attention has just been called to a criticism in the 'Association
Journal,' of October 31st, by an officer of the ex-Committee of Arrange-
ments for the International Medical Congress, of a letter of my own,
which appeared in your issue of October 10th.
"The effort reminds me so much of a cobbler striving to patch with
flimsy material his originally bad work, that I might complacently afford
to stand in my old shoes. But, for the benefit of my professional
brethren, who may, through inadvertence, be deceived, I will notice
only the two points in the criticism which may seem to affect my posi-
tion. My letter stands as the public record of my action in the com-
mittee.
"1. I am accused of having 'persistently endeavored to obstruct
the proceedings of the committee' (at the meeting in New York on the
3d and 4th of September) ' by frittering away valuable time with trivial
objections.' These objections of my own are on record, and need not
be defended. No doubt they were annoying to some. But the author
592
MISCELLANY.
[N. Y. Mkd. Jopb.
of the complaint has inadvertently paid me a very great compliment)
for which I am grateful. To 'obstruct proceedings' which I have
shown to be irregular and prearranged by certain parties to advance
their special ends, regardless of the unity, harmony, and well-being of
the profession, can only be regarded by proper-thinking persons as a
meritorious act.
" 2. Next it is stated that I complained that ' a letter which he (I) for-
warded to the temporary secretary was not read before the meeting of
the committee in Chicago, or embodied in the report which was recently
published.' My letter is referred to as on a par with two hundred let-
ters received from other parties (not members of the committee), to
have read all of which would have occupied the entire day The com-
mittee, it is stated, only directed that a letter from Dr. Austin Flint, Sr.,
should be read.
" The above is not a correct statement of facts. I was, together
with Dr. Austin Flint, a member of the Committee of Arrangements,
and did not, therefore, occupy the same position with two hundred per-
sons who may also have written letters, but who were outside of the
committee. I had, therefore, equal right with Dr. Flint. As a member
of the committee, unable to attend the Chicago meeting, 1 sent my let-
ter addressed to both the chairman and secretary, waiving the fact that
they had usurped their positions. I had an equal, if not a better, right
than Dr. Flint to express my views by letter. He w as represented l.\ a
proxy. After this proxy took his seat in the committee, Dr. Flint was,
for the time being, not a member of the committee. But, further, the
proxy was there to step in as a permanent member of the committee
when Dr. Flint, in accordance with previous arrangement, stepped out.
Possibly, as I was not connected with this or any other previously
arranged programme, my letter was unimportant, and Dr. Flint's alone
was accorded a reading. Had I occupied a like distinguished position
in the eyes of the managers, or been as available for. promotion from
the ranks of the committee to the highest office in the Congress,.!
might have been accorded equal rights with my illustrious friend.
''Still, I am satisfied with my present humility, and would not ex-
change this for the highest office bestowed by the committee."
The Health of Chicago. — By the Health Department's " Condensed
Statement of Mortality" for October, it appears that the following
deaths from infectious diseases were reported : 1 from small-pox, 1
from measles, 27 from scarlet fever, 81 from diphtheria, 30 from croup,
8 from whooping-cough, 1 from typhus, 33 from typhoid fever, 6 from
cerebro-spiual fever, 5 from malarial fevers, and 32 from other zymotic
diseases.
THERAPEUTICAL NOTES.
Digitalis as a Corrigent of the Effects of Quinine on the Heart. —
Talma and van der Weyde ("Ztschr. f. klin. Med."; " Ctrlbl. f. klin.
Med.") state that small doses of quinine exaggerate the diastole of both
the auricles and the ventricles, without notably reducing the systole ;
but that large doses increase the diastole still more, and render the sys-
tole imperfect, so that suspension of the heart's action may occur in
diastole. If digitalis is given in addition, however, the ventricular
systole is rendered almost perfect, and the auricular distension at the
same time moderated, which accounts for the good effects of digitalis
in acute dilatation of the heart from quinine poisoning.
Hamamelis in the Treatment of Prostatic Enlargement and of
Buccal Cancer. — Dr. Duncan J. Mackenzie writes to the " British Medi-
cal Journal," saying that irrigation of the bladder with a mixture of a
drachm of tincture of hamamelis, half a drachm of carbolic acid, and
about twenty-five ounces of warm water, arrested periodical haemor-
rhages from the urinary passages and the rectum in a case of prostatic
enlargement under his care, and so reduced the congestion as to enable
him to discontinue the use of the catheter. In another case, marked
palliation, including the control of a hemorrhagic tendency, followed
the internal use of hamamelis, the case being one of cancer of the ton-
sil and of the tongue.
Two American Species of Aconite. — In the current number of
" Drugs and Medicines of North America," Dr. Roberts Bartholow, of
Philadelphia, relates certain experiments with Aconitum Fixcheri and
A. uncinatum, and gives the conclusions that he has drawn from them.
Aconitum Fixcheri grows abundantly in the mountainous regions of the
western section of the United States, and the author thinks it gives
every indication of rivaling the imported drug in activity and value.
There are, however, marked and fundamental differences between its
physiological action and that of A. napellus, which may be stated as
follows :
Aconitum napellus. Aconitum Fixcheri.
Affects sensibility and lowers Does not affect the tactile or
the irritability of the sensory pain sense, although it causes the
nerves. characteristic tingling; and does
not affect the irritability of the sen-
sory nerves.
Paralyzes the end-organs of the Does not affect the contractility
motor nerves, the trunks, and ulti- of muscles or the irritability of the
matelv the motor portion of the motor nerves, but paralyzes the
cord. motor centers of the cord.
Stimulates the vagus roots and Paralyzes the pneumogastric and
slows the heart ; after a brief increases the force and number of
stimulating action, paralyzes the the cardiac pulsations ; rather
vaso-motor center in the medulla, stimulates the vaso-motor center,
and greatly lessens the blood press- and does not lower the blood press-
ure, ure.
Both cause death by paralysis of respiration.
As regards A. uncinatum, the author thinks it is practically inert,
although very large doses appeared to heighten the cutaneous and cor-
neal reflexes a little in frogs.
Hydronaphthol as an Antiseptic. — At a recent meeting of the Phila-
delphia Academy of Surgery, Dr. R. J. Levis read a paper entitled
"Notes on the New Antiseptics, Hydronaphthol and the Potassio-mer-
curic Iodide " (for proof-slips of which we are indebted to the courtesy
of the "Philadelphia Medical Times"), in which he stated that his own
experience with hydronaphthol in the wards of the Pennsylvania Hos-
pital and in private surgical practice had confirmed the observations
set forth by Dr. George R. Fowler, of Brooklyn, now in course of pub-
lication in this journal.
Hydroquinine as an Antipyretic. — According to Seifert (" Berlin,
klin. Wchnschr." ; " Union med."), this derivative of quinine has anti-
thermic properties resembling those of quinine and superior to those of
salicylic acid and kairine, and produces neither delirium, ringing in the
ears, nor headache. It appears to be rapid in its action and free from
unpleasant effects, even on continued use, and it is to be recommended
for children. It reduces the pulse and the temperature and causes free
sweating. Its cost is about the same as that of quinine.
Thalline and Antipyrine in the Treatment of Febrile Diseases. —
M. Jaccoud (" Gaz. hebdom. de med. et de chir.") lately reported to the
Paris Academie de medecine the results of his experience with these
drugs in cases of typhoid fever, tuberculosis, pneumonia, and erysipe-
las, and laid particular stress on the transitory character of their ef-
fects. He believes that the cpurse of the disease is not at all influ-
enced by them, and that by using them we are merely playing with the
surface-radiation of heat. Therefore he does not consider them solid
additions to the materia medica.
Bismuth in the Treatment of Sweating Feet. — The "Union medi-
cale" cites Vieusse's recommendation of daily frictions with subnitrate
of bismuth as a remedy for foetid perspiration of the feet. The spaces
between the toes should not be forgotten. The treatment is to be con-
tinued for about a fortnight. After the second or third friction, the
sweating becomes less abundant, and the soreness rapidly subsides.
The epidermis soon loses its white tint, and adheres more firmly to the
subjacent derma, the excessive action of the sudoriparous and sebace-
ous glands diminishes, the perspiration becomes less irritating, and
about the sixth day the skin resumes its natural look.
An Untoward Result of a Submucous Injection of Chloroform is re-
ported by M. Blocq (" Progr. med."; "Ctrlbl. f. chir."). Five or six
drops were injected into the gum, as has been recommended for tooth-
ache, and immediately an intense and painful swelling of the face took
place, followed by rather extensive sloughing of the mucous membrane
of the upper lip and the gum, suppuration that lasted for months, and
superficial necrosis of the maxilla.
THE NEW YORK MEDICAL JOURNAL, November 28, 1885.
(Original Communications.
REMARKS ON
EXCISION OF THE HIP*
By LEROY MILTON YALE, M. D.
An apology is perhaps due to the society for again
■bringing up so well-worn a subject as excision of the hip.
But, as it is one upon which surgical opinion is far from
unanimous, its consideration must be always in order until
the value of the operation is better settled than it yet is.
The more recent views concerning tubercle and the rise of
antiseptic surgery have stimulated the resort to excision in
hip disease. Aseptic methods have now been long enough
employed for considerable experience to have been accu-
mulated as to their effect upon the ultimate results of the
operation. This paper is the outcome of an attempt to as-
certain from the periodical literature of the last six or seven
years what this experience has been, and whether any con-
clusions could be drawn from it regarding the indications
for resection in hip disease. Although tolerably familiar
with the difficulties of the question, 1 confess I was some-
what surprised at the scantiness of the material which came
to hand that was valuable for exact comparisons.
The grounds upon which resection of the hip is urged
as preferable to non interference are usually three :
1. That it directly saves life.
2. That it shortens treatment, and, by so doing, lessens
risks both vital and functional.
3. That it gives better functional results.
There can be no manner of doubt that the operation
often saves lives that otherwise must certainly have been sac-
rificed. Such operations in extremis have been aptly com-
pared to tracheotomy in like conditions. Under such cir-
cumstances failures should not be counted. Every success
should be esteemed a clear gain, and even prolongation of
life and mitigation of suffering be reckoned in favor of the
operation. About such resections there is probably no
question. The inquiry is rather this : Comparing cases as
nearly as possible similar, at what period, or under what
circumstances, do the results obtained by excision become
preferable to those gained by less radical measures ? And it
may be here remarked that a good deal that has been said
regarding the relative value of early or late operations is
rather beside the question, for there is little doubt as to
their comparative success. The issue is between the opera-
tion at all and conservative methods, and the former is
clearly indicated whenever it can be shown to give better
prospects for life than the latter.
The value to be set upon resection, therefore, depends
very largely upon what is held to be the natural tendency
of the disease, and upon what success can be gained by
conservative treatment. And right' here, at the start, we
find a divergence of views so wide as to go far toward ex-
plaining the unsettled condition of opinion regarding the
operation. The most gloomy statements come from German
* Itead before the New York Surgical Society, November 10, 1885.
authors. Thus Billroth gave the death-rate of his cases,
some of which were followed after leaving the hospital, at
31^ per cent., taking, if I understand correctly, all cases.
Hueter,* from hospital records alone, gave 26f per cent.
The two lists united give 28f per cent. Nowhere else is
the death-rate set so high when all stages of the disease are
considered together. From reports for several years of the
Orthopaedic Hospital of this city, I find that the deaths and
discharges on account of incurability together make an an-
nual average of about 4f per cent, of all cases treated.
Gibney's f statistics from the Hospital for the Ruptured
and Crippled give for 288 cases a mortality from all causes
of per cent. Taylor's J statistics, which give (deduct-
ing one case of violent death) 2 deaths in 93 cases, or 2\
per cent., can not be fairly quoted here, as they were drawn
from a private practice among well-to-do people.
Although exsection has of late been done quite early in
the disease, yet it would be obviously unfair to make any
comparison between the death-rate of these collections of
cases in all stages and the most favorable operative statis-
tics. Again, although exsection is frequently done when
destructive changes are recognizable in the joint, but before
suppuration is evident, I know of no extended statistics of
the corresponding cases treated conservatively. A few cases
will be mentioned further on. But, regarding suppurative
coxitis, we have more distinct expressions of the results of
experience, and some statistics. Here, again, Hueter's esti-
mates exceed others in gravity. While acknowledging the
absence of exact information, he states that he should be
surprised if statistics should show that more than 50 per
cent, of cases that reach the " second florescence stage " (the
stage of flexion, adduction, and inward rotation) ever were
healed. And he further states his belief that " suppuration
of the hip joint — if the cases in which a single small abscess
forms and quickly closes again, and also the cases of scanty
suppuration in the granulations of synovitis hyperplastica
granulosa are subtracted — is a nearly absolutely fatal pro-
cess." * Volkmann || is by no means so hopeless. Oilier A
thinks that " the greater part of the suppurative coxalgias of
children may be cured by methodical expectation, aided by
the resources of hygiene." Taylor lost 2 out of 24 suppura-
tive cases, or 8^ per cent. This, as before stated, was in
private practice. The committee of the Clinical Society of
London Q set the mortality of cases of suppurative hip dis-
ease, treated expectantly, at 33^ per cent, from all causes ; or,
leaving out causes unconnected with the disease, at 31*6 per
cent. Cazin J gives the result in the cases of 80 patients
treated at the hospital at Berck, sent from a Parisian hos-
pital after they had failed to improve there. All but ten
* " Klinik der Gelenkrankheiten," S. 142.
f Tbe Strumous Element in the ^Etiology of Joint Disease, " New
York Medical Journal," July and August, 1877.
X Observations on the Mechanical Treatment of Diseases of the Hip
Joint, "Boston Med. and Surg. Jour.," March 6, 1879, p. 318.
* c, p. 641.
| Resectionen der Gelenke, " Samml. klin. Yortr.," No. 51, p. 2.
A "Revue de chirurgie," 1881.
Q "Transactions," 1881.
$ "Bulletin et memoires dc la societe de chirurgie," Paris, 1S7i'..
594
YALE: REMARKS ON EXCISION OF THE HIP.
[N. Y. Mkd. Jodb.,
of these were grave cases, and 5 per cent, were already
albuminuric when received. The statistics cover five years;
55 per cent, were cured, 12£ per cent, died, 7£ per cent,
were benefited, and the remaining 25 per cent, were not
cured when removed. This remarkable success f<>r cases of
such severity may, perhaps, be not fairly introduced here,
as the patients, although belonging to the hospital class,
were at Berck under excellent hygienic influences, and were
systematically treated.
Gibney,* out of 80 patients with hip disease cured with-
out mechanical treatment, found 48 that had had abscesses.
No percentage of mortality can be made here, as the total
number having had abscesses that were treated is unknown;
but this number of recoveries under a plan of the purest ex-
pectancy shows that suppurative coxitis can not be nearly so
grave an accident as some have estimated it to be. As an
offset, however, may be mentioned 19 patients recorded by
Caumont,f treated conservatively, of whom 12 (63'1 per
cent.) died.
From these discordant figures and opinions it seems to
me fair to conclude that their disparity is not the result of
the bias of different observers, but that in some communi-
ties or districts circumstances may so influence the course
of the disease as to make an actual difference in the facts, as
well as in the interpretation of them. To express an opinion,
therefore, as to the average mortality of suppurative coxitis
may be hazardous, or even presumptuous. Nevertheless,
my own observations lead me to accept the more moderate
estimates as the more nearly correct, and I should consider
that the rate set in the Clinical Society's report was amply
large ; that is to say, that the death-rate would not exceed
30 per cent., even among the poor, at least as we know pov-
erty in this great city. In private conversations, Dr. Gib-
ney and Dr. Shaffer, of this city, both of whom have had
unusual facilities for knowing the results of hip disease
among the poor, expressed the opinion that the estimate I
have given was very liberal, and would considerably exceed
the facts.
Now, as to the death-rate of excision. Leisrink's often-
quoted tables set it at 63*6 per cent., J but this high figure
is reached by setting aside all unhealed cases as worthless,
which is a source of error, as many such cases go through
the same course as unoperated cases and reach an ultimate
cure, perhaps by ankylosis, after a long time. If all of Leis-
rink's cases had been included, his death-rate would have
been 5 7 "9 per cent. Say re's* table gives 72 cases (two
being still under treatment), with 25 deaths, or 34*7 per
cent. Culbertson's tables contain 418 cases, with 174
deaths, or 41*62 per cent. If uncertain cases, 30 in num-
ber, are excluded, the percentage will be 44-84. All these
collections contain cases observed for quite a long time, and
this death-rate is by no means that of operation. Culbert-
son gives only 29 deaths as immediately resulting from the
operation — that is, 6*93 per cent, of all cases. This is in-
teresting as show ing that even before the advent of antisep-
* "Medical Record," vol. xiii, p. 174.
f " Deutsche Ztschr. f. Chirurgie," Bd. xx, S. 137.
\ Langenbeck's "Arch. f. klin. Chirurgie," Bd. xii, S. 177.
* " Orthopaedic Surgery," 2d ed., p. 347.
tic surgery the operation, as such, added but little to the
general mortality from hip disease.
Many lists published since the beginning of antiseptic
surgery contain cases treated in both periods, and often no
attempt is made to separate them. " Thus, Cowell,* in re-
porting 65 operations of his own, says : " I now perform the
operation antiseptically," but the results are all grouped
together. It does not appear that these cases were followed
beyond the hospital. There were seven deaths among them,
or 10*77 per cent. Three patients above eighteen years of
age, all died. Of the 62 below eighteen years, only 4 died,
or 6*15 per cent. Here should be placed the statistics of the
Clinical Society's report, before quoted, which gave a mor-
tality of 40 per cent., or, excluding deaths from causes un-
connected with the disease, 37*7 per cent. Holmes's f list —
given in his well-known Address in Surgery — of operations
done in British hospitals belongs to the five years ending
1878, a period during which antiseptic precautions were
coming into use. They should probably be considered as
mixed operations. It does not appear how long the cases
were followed, but, of 215 cases, 40, or 18*6 per cent., ended
fatally, and 57, or 26*5 per cent., failed. Caumont, \ whose
statistics are commendable for the care with which patients
have been traced for years after they left the hospital and
carefully classified, records 42 cases, with 26 deaths, 61*9
per cent. Only 5, or 11*9 per cent., died from the opera-
tion. The remaining 50 per cent, were from progressive
caries, amyloid changes, and tuberculosis. His death-rate
before antisepsis was 66 per cent. ; since antisepsis, 41 per
cent.
Of operations entirely antiseptic, Volkmann * reports 48
with but 4 deaths, or 8-J per cent. Two only of these (from
shock) were strictly deaths from operation ; the third, after
two months, was from thrombosis, and the fourth, after
three months and a quarter, from haemorrhage from ulcera-
tion of an artery, due to a suppurating scrofulous gland.
Volkmann estimates that 8 or 10 would subsequently prove
fatal from the progress of the disease, which would run up
the death-rate to 25 or 30 per cent. Korff || reports 16
deaths out of 33 cases treated antiseptically (48*48 per
cent.), the death-rate diminishing steadily as the methods
were improved, being 75 per cent, when Lister only was
used, 52*63 per cent, with a modified Lister, and 30 per cent,
with a bichloride and salt gauze dressing. Grosch A bases
his statistics on 166 cases treated antiseptically; 120 of
these were observed to the end, with 44 deaths, or 36*7 per
cent. He divides his cases into three stages. The first
contains those operated on with unruptured capsule and
slight changes in the joint ; the second, cases with abscess
and fistuhe ; the third, cases with long suppuration, exten-
sive destruction of the joint with great debilitation. In the
first class there was for children no death-rate ; for the sec-
ond, it was 24*1 per cent.; for the third, 67*5 per cent.
* "British Med. Journal," 1882, ii, 360.
\ Ibid., 1880, ii, 212.
% " Deutsche Zeitung f. Chirurgie," Bd. xx, 1884, Heft 3 and 4.
* " Verhandl. d. deutsch. Gesellsch. f. Chirurgie," 1877, S. 59.
I " Deutsche Ztschr. f. Chirurgie," Bd. xxii, S. 149.
A Inaugural Dissertation, Dorpat, 1882, Abstract in " Centralbl. f.
Chirurgie," 1882, S. 228.
Nov. 28, 1885.]
YALE: REMARKS ON EXCISION OF THE HIP.
595
Further, he found that for the period 1876- 82, after anti-
septic methods were well established, the death-rate was 9
per cent, less than for the period 1870- 75, in which these
methods were forming. Quite recently Alexander* gives
the results of 36 operations apparently all done and dressed
antiseptically (chloride of zinc and Lister). One patient
only died of operation (shock), 2-77 per cent.; 10 more
from disease. Total death-rate, 30-55 per cent.
It will at once be seen that statistics gathered in such
different ways, and to bring out different aspects of the
question, can not be closely compared with hope of an exact
result. But, if I have correctly apprehended the general
import, it is this : that the mortality after resection of the
hip joint has materially diminished since the introduction
of antiseptic precautions, and that the diminution corre-
sponds very closely to the death-rate formerly chargeable
immediately to the operation itself. Take the extensive
tables of Culbertson ; setting aside uncertain cases, he had
a total death-rate of 44-84 per cent. ; deducting deaths from
operation — 6-93 per cent. — we have 37-91 per cent., which
is very nearly the same as Grosch's — 36*7 per cent, for 120
completed cases under antiseptic treatment. In other words,
asepsis has almost abolished the risks from wound complica-
tions, and the death-rate is reduced very nearly to that from
the uninterrupted disease when the operation has failed to
arrest it.f And, as it has been shown that, in cases that
heal, the period of healing is shorter than when antiseptics
are not used, the danger of amyloid changes may be slight-
ly lessened. Thus much has been gained by perfect antisep-
sis ; in weighing the chances in any given case, we need no
longer put much stress on the dangers of the operation itself,
except, perhaps, the one element of shock, which the pro-
longed extirpation of diseased and suspected tissues, neces-
sitated by the thoroughness of modern surgery, sometimes
favors. It seems, then, fair to say that whenever the disease
in its natural course assumes an aspect threatening to life,
resection is indicated, provided none of the less radical op-
erations— drainage, gouging, etc. — can remove the danger.
It has just been mentioned that very early operations,
done while the changes in the joint are slight and the cap-
sule unruptured, have given no death-rate, or almost none.
But, on the other hand, the disease itself has practically
no death-rate at this stage. Occasionally general or visceral
tuberculosis may occur thus early, but rarely. Amyloid
changes and exhaustion do not enter here as causes of death.
It does not appear, then, that there is thus early any vital
indication for excision. The early operation has been urged
as vitally indicated in forestalling tuberculosis and the
other attendant risks of morbus coxarius by cutting short
the disease. If it could be proved that such prevention
actually followed the operation, it would be a weighty argu-
ment. As Grose h points out, tuberculosis is still the com-
monest cause of death. Konig J maintains, as a result of a
* " Liverpool Med.-Chir. Journal," 1885, p. 289.
f At first sight it would seem as if more had been accomplished,
but, as Grosch's statistics contain only early eases of a kind that scarce-
ly appear in Culbertson's, the comparison is not quite upon an equal
basis.
\ Ueber die Resultate der Gclenkresektionen, etc., " Verhandl. der
deutsch. Gesellsch. f. Chirurgie, IX. Kongress"; also, Die Fruhrescction
large experience in excision of all kinds — 117 in three years
and a half — that the hope for immunity from tubercular
infection has not been gained by antiseptic resection. Of
25 deaths after his operations, 18 were from tuberculosis,
and in addition nine patients, not yet dead, were hopelessly
tuberculous; in all, 21-5 per cent, of his cases; and of 21
hip excisions, 10 — 47*6 per cent. — died of tuberculosis in
four years. In the debate on Konig's paper some disa-
greement with his views was expressed, but Esmarch essen-
tially confirmed them. Caumont* distinctly states that he
found no preventive effect in his cases. Of 26 cases of
scrofulous origin treated by expectancy, he lost 5 — rather
less than one fifth — from tubercular disease; of 12 resect-
ed, he lost 4, or one third. Others may have had better
results, but the prophylactic effect can not be very decided
if such marked exceptions occur.
Nor is it clear that destructive changes in the joint
without evident suppuration often present a vital indication
for excision. A vicious form of caries, characterized by
great suffering and great destructiveness of tissues without
much pus formation (caries sicca) is probably best met by
resection. But of ordinary caries this is not true. It is a
matter of common experience to find cases in which the
destructive process is evidenced by the misplacement of the
trochanter, which go through the whole course to recovery
without any external evidence of suppuration. Caumont
has taken the trouble to place such cases by themselves in
his report. Of those treated expectantly, 25 per cent, died ;
of those exsected, 50 per cent.
It is not until suppuration has taken place that any
vital indication for resec' n appears. Even here I believe
the dictum of Hueterf is ar too sweeping when he says:
" I hold resection of the hip joint in coxitis to be indicated
as soon as an extensive suppuration of the joint manifests
itself, or as soon as the course shows that the termination
in suppuration can be no longer prevented." Such a state-
ment, however, is the natural outcome of his extremely
gloomy views' of the results of suppuration. If the opinion
I have expressed as to the prognosis of suppurative coxalgia
is anywhere near a correct one, resection is only indicated
in a minority of cases. The indication comes not from the
existence, but from the persistence, of suppuration. If it
persists after the drainage of the abscesses and under the
best hygienic resources the patient can command, particu-
larly if fever attends the suppuration, then exploration of
the joint is indicated, by incision or dilatation of existing
fistulae, with resection or a less extensive extirpation of the
diseased parts, as the condition found may demand. And
this should not be delayed after the system shows distinct
depression from the suppurative process. To wait until the
operation is the only escape from impending death is to err
on the side of ultra-conservatism. I have not mentioned
necrosis or sequestra in the joint, because under such cir-
cumstances some operation for the removal of the dead
bone is imperative. Likewise, if perforation of the aceta
bulum with pelvic abscess exists, we have no resource but
bei tuberculoaer Erkrankung der Gelcnke, etc., " Archiv. f. klin. Chirm-
gie," Bd. xxvi, S. 822.
* Loc. cit. \ L. p. 653.
596
YALE: REMARKS ON EXCISION OF THE HIP.
[N. Y. Med. Jooh.,
resection. True dislocation of the femur with suppuration
of the hip joint is of very rare occurrence in ordinary hip
disease, and the indication for excision often urged in this
connection is rather orthopajdic than vital.
A few words may be said regarding the second claim,
that, namely, resection shortens the period of treatment, and
that it diminishes the risks, both vital and functional. This
is true of those cases that heal promptly and soundly, but only
of such. Beside those that are fatal there is a long series of
cases in which the patients neither die nor heal, but live
years with persistent fistulas. In Leisrink's tables 12*5 per
cent, were " unhealed " ; in Ilolmes's, 26-5 per cent, were
" failures." Such cases now are often spoken of as " re-
lapses." Asepsis favors prompt healing of the soft parts,
but the union subsequently in many cases breaks down, and
the old process is re-established under circumstances in no
way improved. Just how frequent these "relapses" are I
can not say, but they are often mentioned as " common."
My own observations make them about 20 per cent, of all
cases operated on. A friend who was in Kiel the past sum-
mer quotes Neuber as saying that " about half " of his cases
relapsed. This refers, I understand, to the reopening of the
wound, with tubercular granulations of its edges. Many of
these ultimately do well after excision of the diseased parts.
Lastly, as to function. It is far from proved that resec-
tion gives better average results than a " natural " cure. In
the question shortening is not the most important element.
The shortening from resection is on the average greater than
from Datural cure, but not so very much. In a case not re-
sected, but of such severity as to bring the operation into
consideration, the growth of bone from the upper extremity
will have been considerably retarded or arrested, according
to the degree in which the epiphyseal cartilage has been af-
fected. In a case resected the growth will be entirely abol-
ished, and some bone already produced must be sacrificed.
Oilier * points out that, although the total growth in length
from the lower extremity of the femur amounts to about
twice that from the upper, yet during the first four years
of life the two ends contribute about equally, and that after-
ward the lower increases in activity until its work is, toward
the end, about three times that of the upper. The progno-
sis as to length, then, will vary with the age at which exci-
sion is done, very early excision giving much the greatest
ultimate shortening. The leaving of the greater trochanter
does not much affect this relation, for what it contributes to
growth in length is mainly above the joint and does not
much increase the efficient length of the bone. The atro-
phy from inactivity affects the whole limb and is not mate-
rially different in cases resected from those left alone. If a
resection was promptly successful, the advantage ought to
be in favor of the operation, as permitting more speedy use
of the limb.
Again, a useful joint in a lower extremity must be sta-
ble, as well as mobile. And for most occupations security
in the support of the trunk is more essential than motion
at any one joint. Mobility with security at the hip after
excision is only obtainable when very strong fibrous attach-
ments exist between the pelvis and the remainder of the
* "Revue de chirurgie," 1881.
femur. The destruction from the disease and the necessary
extirpation of affected tissues usually prevent the forma-
tion of attachments at once strong and flexible. Exceptions
occasionally occur, and some very brilliant results have been
obtained in which stability existed with very free motion.*
Some very remarkable attempts at renovation of a hip joint
have occurred, and interesting specimens have been de-
scribed.! Nevertheless, as a rule, the motion, if considera-
ble, is combined with such feebleness of support that the
femur rides up and down on the pelvis in the act of walk-
ing. " Flail-joint," in the usual acceptation of the term as
meaning uncontrollable motion in various directions, is
rare, and I do not remember to have seen it. It is this in-
security that has led some operators (Oilier, Caumont) to
urge that, if the operation is made very late, or in cases
where much local damage has been done, if the patient
must earn his living, it is better to strive for ankylosis
rather than mobility. A fortiori, the ankylosis of a natural
cure, the limb on the average being longer than after excis-
ion, will give for such persons a more useful limb. The com-
pensating mobility of the spinal articulations, if the disease
occurs in childhood, is often marvelous. The most striking
instance I ever saw is No. 31 in Dr. Sayre's tables of ex-
cision ; the motion took place in the lumbar spine, not only
antero-posteriorly, but laterally, through a wide arc. Statis-
tics (Grosch) show no better functional results for antiseptic
operation than were formerly obtained. Functional reasons
strengthen the indication for the substitution, whenever pos-
sible, of the simple extirpation of diseased tissues for formal
excision in that they disturb less the relations of parts.
These less radical performances are by the perfection of
aseptic precautions rendered safe, and the large removals of
bone formerly necessary to prevent accumulations of pus
and septic matter seem no longer essential. In the same
direction improvement of functional results may be hoped
for by the employment in proper cases of the operative
manoeuvres in which a partial or temporary removal of the
trochanter only is resorted to, the muscular attachments
being little disturbed.!
Further, it should not be forgotten that good functional
results as to position and motion can only be obtained by
prolonged after-treatment. Neglect in this particular con-
stantly produces great deformity, and the care required to
secure these good results quite answers the claim already
alluded to — that resection is a short road to cure.
The conclusion, then, to which the foregoing brings us
is, that exsection of the hip is indicated as a life-saving
operation only ; and that, as it has not been shown that it
can save from any dangers except those consequent upon
prolonged suppuration, it is, with rare exceptions, only in-
dicated when the suppurative process has evidently reached
a dangerous point, and can not be interrupted by any less
serious operation.
* See, for example, several cases figured in Sayre's " Orthopaedic
Surgery."
\ Sayre, I. c, frontispiece, 2d ed. ; Kiister, "Archiv f. klin. Chirur-
gie," Bd. xsix, 409; Israel, Ibid., p. 411.
% Oilier, I. c. ; Konig, "Centralbl. f. Chirurgie," 1882, S. 457 ; Neu-
ber, Ibid., 1884, Beilage, S. 75.
Nov. 28, 1885.] ELSNER : TYPHOID FEVER AS WE SEE IT IN CENTRAL NEW YORK.
597
TYPHOID FEVER
AS WE SEE IT IN CENTRAL NEW YORK.*
By II. L. ELSNER, M. D.,
SYRACUSE.
It is not the writer's object to give you a treatise on
typhoid fever — its pathology, symptoms, and everything
pertaining to that disease — in the space of this essay. That
has been done by others whose accurate and keen observa-
tions have been given to the profession during the last
twenty years. For the typical cases of typhoid we can find
no better authorities than Griesinger, Liebermeister, Lebert,
Murchison, and a score of others. All physicians who have
been in active practice and seen a fair number of fever pa-
tients are well aware of the fact that in central New York
but few of their cases follow the train of symptoms laid
down in our leading text-books on typhoid fever. The
cases that do follow exactly the descriptions of our leading
authorities are rather the exception than the rule. Our
cases are without the characteristic or typical temperature-
curve. Their symptoms do not follow each other in regu-
lar order; in fact, their course seems different from the
cases collated. The object of this paper is to lay before
you the result of my clinical experience with the disease
mentioned, and to prove to you by my records that our
cases are atypical. In central New York you will have no-
ticed that each year our fevers show some different phase ;
that each endemic has its characteristic manifestations,
which cause it to differ from the typhoid of the previous
year. Some epidemics, or even isolated cases, are influ-
enced by a large and powerful malarial element ; others are
associated with complications changing the entire course of
the disease, or markedly modifying it. Let us look, first,
to the prodromes of the fever as we see it. In not a few
cases of pure typhoid we have found our patients present-
ing, with a high temperature, following a more or less severe
chill without having experienced a single prodromal symp-
tom. In these cases there was no gradual rise to a higher
temperature ; but without prodromes we are at once plunged
into a state of affairs which we would hardly expect in typi-
cal cases before the end of the fifth or seventh day. In one
case, seen with Dr. A. S. Edwards, the patient was taken
suddenly, on returning from his work, with a slight chill
and a temperature of 104° F., all symptoms warranting the
diagnosis of typhoid. Death took place on the sixth day
of the disease. On post-mortem examination we found the
enlarged spleen and mesenteric glands, with the characteristic
appearance of Peyer's patches. These lesions at once proved
the case to be typhoid beyond a shadow of doubt. Some
of the cases do have the usual prodromes well marked ; but
the fact is established that, in a goodly number of our
cases, there is an entire absence of prodromes ; that in a
few cases the gradual rise of temperature does not take
place, but we have at once a high temperature followed by
the characteristic rise and fall of the second week of ty-
* Read before the Third Branch of the New York State Medical
Association, June 9, 1885. A number of temperature charts were
shown at the meeting, but, in order to save space, they are not pub-
lished.— Editor.
phoid. For the confirmation of this fact I would refer you
to Charts K, O, and P. In children we frequently find a
prodromal stage of catarrhal symptoms showing themselves
in catarrhal bronchitis or broncho-pneumonia. I will not
detail the history of patient M. L., but refer you to Chart
Q, where there was a pneumonia followed by catarrhal
bronchitis, and finally typhoid, with alarming haemorrhage,
on the thirtieth day of his sickness. In those cases not at
first burdened with some complication we are safe in saying
that violent chills are rather the exception than the rule.
Most frequently there are sensations of cold, as " cold shud-
ders" or "cold streaks." These sensations continue usually
during an entire day, and are accompanied with headache.
Violent chills occur in those cases with an intermittent ten-
dency. In most cases we have the usual malaise, change of
disposition, and listless and disinterested manner of the pa-
tient. Gastric disturbances are found in some cases during
the first days of the disease, taking the place of other early
symptoms. It is often difficult in these cases to give a posi-
tive diagnosis, for we may be justified, if there are also diar-
rhoea and abdominal tenderness, in diagnosticating gastro-
enteritis, or some other abdominal disease with like symp-
toms. In these cases the epistaxis and facial appearance of
the patient will aid in making the diagnosis. Gastric irri-
tability continuing into the second and third week is a
serious and often unfavorable symptom. In 60 per cent, of
my cases there was an early diarrhoea ; 40 per cent, of the
patients suffered from constipation. This constipation is
often obstinate, and, before resorting to any measure di-
rected toward its relief, we are warned by the ileo-caecal
tenderness, and the other symptoms, that the patient has
enteric fever.
A small admixture of blood is sometimes found in the
stools during the first days of the disease, while in two
cases I have found a free discharge of blood. In the first
of these cases this bloody discharge was the symptom which
led the patient to seek medical advice. In the second case
there was a distinct venous haemorrhage. These early
haemorrhages were found in cases of enteric fever with
marked malarial symptoms. In some of our cases the diar-
rhoea was superseded by an obstinate constipation. In not a
single case of typhoid disease have I been unable to detect
tenderness in the region of the ileo-caecal valve at some time
during its course. This ileo-caecal tenderness is not influenced
by the severity of the disease or the amount of ulceration. It
is present in all cases of typhoid fever, however mild or severe
the manifestations. To this point I have given the closest
attention in the examination of my patients, and it is one
which I can positively assert. In typhoid fever, as we see
it, epistaxis is one of the most frequent symptoms. In some
cases it is mild, in others of sufficient gravity to require
surgical interference. Early profuse nose-bleed is more fre-
quently found in the severer forms of the disease. Nose-
bleed profuse after the tenth day is always to be regarded
as an ominous sign. There is no characteristic appearance
of the tongue in our forms of typhoid fever. Some of our
cases have led to the death of the patient after severe haemor-
rhage or perforation, with a moist tongue from the first to the
last day of the disease. In some of the most critical cases of
598
ELSNER : TYPHOID FEVER AS WE SEE IT IN CENTRAL NEW YORK. [N. Y. Med. Jo< k.t
typhoid that I have seen there has been a moist, red-tipped
tongue throughout the course of the disease. Repeatedly
we find the dry, hard, cracked tongue, bleeding at its edges,
with sordes on the teeth. This appearance of the tongue
is found in the graver forms of the disease. We are more
likely to find intestinal haemorrhage and other intestinal
symptoms in a case with the dry tongue than with the moist
tongue. The pulse goes hand in hand with the temperature
during the height of the disease ; after severe haemorrhage
it is more rapid, and even dicrotic. If the temperature is
high the pulse is correspondingly high. I hardly think
that any one of us could diagnose typhoid fever from an
examination of the pulse, as there is nothing characteristic
in it, any more than a physician could tell the true state
of a fever patient without the daily use of the thermome-
ter. The roseolar eruption is usually present ; only oc-
casionally do we fail to find it ; when I have failed I have
thought that it was overlooked. In some cases the erup-
tion is quite profuse, but in the majority it makes its
appearance at the time and in the manner mentioned in
the books. In most of the cases of haemorrhage I have
noticed a fall of temperature, at some time during the
twenty-four or thirty-six hours preceding its appearance, ex-
ternally. Some of our patients seem to mend rapidly after a
single haemorrhage, but, when oft-repeated and large, they
tend to debilitate the patient, and finally death may ensue
from exhaustion. There is nothing noteworthy in the be-
havior of the haemorrhage, and we pass to the considera-
tion of the question of malarial influence on our forms of
typhoid. To me it does not seem possible that a patient
who has typhoid germs floating in his blood can not modify
the symptoms arising from that condition by the admixture
of malarial poison. I have thought that our typhoids were
markedly influenced by a malarial element, and am now
positively convinced by clinical experience. Often we are
called to attend patients with typhoid who have gone safely
through all the stages of the disease, each stage marked by
characteristic periodicity. After convalescence has com-
menced, and our patients are doing nicely, we find them
suddenly with severe chill, elevation of temperature, pro-
fuse perspiration and exhaustion following. This condition,
if not treated, is likely to recur at a corresponding hour in
the course of a few days. Quinine, liberally administered,
is sufficient to overcome this trouble. If you will study
the temperature-charts closely you will find that in numer-
ous cases the temperature is higher at periods of the dis-
ease every other day ; again you will find sudden and irregu-
lar elevations of temperature, with profuse perspiration.
These patients have the roseolar eruption, some of them are
accompanied with active delirium, and some have profuse
intestinal haemorrhages. Though the typhoid germs are
in the ascendancy, the malarial element makes a pro-
found impression, and influences materially the symp-
toms and course of the disease. Many of our cases begin
with the symptoms of malarial continued fever, but before
many days assume a typhoid type, show abdominal symp-
toms, and are then true cases of enteric fever. To decide
the subject of temperature-curve, I will not longer weary
you with detailed histories of cases ; but have taken a num-
ber of cases from my daily record, and some from the hos-
pital records, all of which have been faithfully kept, and
appended them to this paper. I could offer many more
charts, but they all show that we have no characteristic
temperature-curve for typhoid fever as we see it in central
New York.
Are there mild cases of typhoid fever? Does our sci-
entific or any other treatment of these cases abort them ?
That there have been mild cases in our midst we can not
deny. In the mildest the patients in my experience have not
been considered convalescent before the end of three weeks,
and in some the convalescence has been very slow. Our
German confreres do not deny the possibility of mild cases
of typhoid, and Jiirgensen has written an able article de-
scribing them in Volkmann's " Klinische Vortrage," No.
61. We can not accept the mere statements of those who
tell us that they abort typhoid fever; if we are called to
see a case of fever of any kind, and our efforts are rewarded
by a fall of temperature and return to normal of the patient,
we can not consider that a case of aborted typhoid. The
accurate, skilled, and careful observer will be cautious how
he makes a diagnosis of any fever during the first week ;
and yet some of our friends would have us believe that
they have cured their patients before we have had time to
make a diagnosis.
To make the diagnosis of enteric fever we must be sat-
isfied that there are abdominal lesions ; without these there
can be no typhoid. During the early days when we are
called to see these cases the symptoms are vague ; there may
or may not have been nose-bleed ; we could not say that a
patient had typhoid fever because he had nose-bleed and
slight febrile disturbance, all of which disappeared after a
day or two of most energetic and polypathic medication.
Those who abort cases of typhoid must first satisfy us that
they have made the proper diagnosis ; must instruct us in
the manner of making such diagnosis, by pointing out the
features of their cases which lead them to its early recog-
nition and ultimate abortion.
In conclusion, I would say that it has not been my
object in this paper to mention all the symptoms of ty-
phoid fever; but it has been my endeavor to attempt at
least to decide, by a careful examination of my records, a
few points which seem to have puzzled and upset us for
some time past in the discussion of the subject under con-
sideration. I think I am safe in concluding that we do
not have as a rule in our cases of typhoid fever a sche-
matic temperature-curve, that they are markedly influ-
enced by a malaria] element, and, finally, that we are only
justified in making the diagnosis of typhoid fever after a
careful examination of the patient, noting each and every
symptom, including thermometric measurements daily for
at least seven days, the abdominal symptoms, roseola, lleo-
caecal tenderness, epistaxis, and then, by the coupling of all
these symptoms and a careful consideration of each, a diag-
nosis can be made.
DISCUSSION.
Dr. Higgin8 : Mr. President, I can not feel at liberty to let
this paper pass without saying a few words and giving my tes-
timony to the faithfulness of Dr. Eisner's description of typhoid
Nov. 28, 1885.| ELSNER : TYPHOID FEVER AS WE
SEE IT IN CENTRAL NEW YORK.
599
fever as we meet with it in this vicinity. And, after a practice
of thirty-five years in an intensely malarial region, I am more
and more impressed that we have few cases of disease of any
character that are not to some degree influenced by malaria.
The point he made I have often observed, of the malaria mani-
festing itself after having passed the patient through that stage
which 1 supposed placed him beyond the need of my care. In
these cases distinct chills with marked regularity, requiring ac-
tive and decided anti-periodic treatment for their suppression,
were the main feature of what is often called relapse. I should
say, however, that these cases were generally of that class that
were allowed to go on from eight to ten days at the outset
without active treatment, the most important period to modify
the disease.
I look upon the paper as one of the most valuable and inter-
esting I have ever heard upon this type of fever, and it interests
me greatly from the fact that in this long period to which I
have alluded our fevers have very much changed in character.
We do not have now, as we did thirty years ago, those positive
characteristics that definitely settled the question as to their
nature. We do not find even those marked and distinct cases
of old-fashioned " fever and ague." We find more prostration
with a commingling of types belonging to different classes.
Those fevers that were termed "bilious remittent" have disap-
peared, or at least the name has, and the word "typhoid " has
the ascendancy over all others. I find very little true typhoid
fever in the vicinity in which I practice, and that, almost with-
out exception, masked by this subtle agency. In fact, I find so
much of this malarial character that I am very cautious how I
use -the word "typhoid," and cases of that type often require
many days to distinguish their true character. But with reference
to abdominal lesions, those cases that develop that form of com-
plaint, there can of course be no question. But what I wished
to speak of particularly were those peculiarly malarial influences
mingling with almost every disease which comes under my no-
tice, and that too in all seasons of the year.
I simply arose, Mr. President, to make my acknowledgments
to my friend, Dr. Eisner, personally, for this very able paper, it
being so faithful a delineation of the disease as it has come un-
der my observation, and being a subject of great public as well
as professional interest.
Dr. Ross: I am very much interested in the doctor's paper;
and while it seems that the type of typhoid fever mentioned by
him is somewhat different from that which I am accustomed to
see, I think, at least in half our cases, we have a comparatively
typical run. There was another fact brought out by the doctor
which is present in almost every case — that of roseola being
found between the seventh and eighth days. Almost all of my
cases have been between the eighth and twelfth days. Another
thing : after an extremely high temperature, often running as
high as 104° at the outset, and a pulse of 110 to 130 during the
first twenty-four or forty-eight hours, the temperature will
drop, then gradually rise, continuing as in a well-behaved case of
typhoid fever.
A great many patients, as we see them, have constipation —
perhaps one third ; some are so much constipated that we are
obliged at times to remove portions of hardened faecal matter
from the rectum with the finger ; the tongue usually assumes a
comparatively typical form.
In regard to aborting cases, I have seen cases begin with
every symptom of typhoid fever — epistaxis, diarrhoea, tympani-
tes, tender abdomen, and delirium, with a gradual rise of tem-
perature for five or six days; then suddenly, whether due to
treatment or to the natural termination of the disease, the fever
drops to normal, other symptoms subside, and the patient is out
within a week or ten days.
I had such a case not more than a month ago — that of a
physician who resided in this city and was in the hospital here, I
believe. He left the hospital and went into the country, where
they were having, or had recently had, typhoid fever. He came
home to Elmira and remained a few days, intending to go to an
adjoining town to practice. The day before his intended start
he was taken with every symptom of beginning typhoid fever.
He had epistaxis, tympanites, delirium, diarrhoea, and a gradual
rise of temperature for about five days, followed by a gradual
abatement of all the symptoms.
Within seven or eight days he was out and about the house.
I have seen such cases again and again, especially when we have
had a large number of typhoid fever patients on baud.
Now, whether these are cases of simple fever or cases of
aborted typhoid fever I am not prepared to say ; the thought
often comes to me that they might be, and there are good, well-
read practitioners who believe this to be possible.
Of course we have no authority for expecting to abort a
case of typhoid fever ; neither do I wish to be considered as ad-
vocating such a theory. I would like to hear on this point the
opinion of other members of the association.
Dr. Brown: My idea of typhoid fever is somewhat different
from that of the last speaker. I believe that typhoid fever,
strictly speaking, is a specific poison ; that it starts out as ty-
phoid fever, and I have contended that the idea of breaking up
typhoid fever is simply ridiculous.
I believe when it is typhoid fever it is typhoid fever from
the commencement; I believe that it is typhoid fever through-
out ; I believe if it commences as typhoid fever it will run a
course as typhoid fever, and, according to my experience in a
large number of cases connected with a school in Pennsyl-
vania several years ago, and published in the journals, where
the infection was caused by drinking-water. There were sixty-
two persons taken sick within three weeks. The shortest dura-
tion of the fever was thirty days, and they ranged from that to
forty and forty-five days. A large majority had haemorrhage
from the bowels and the cases were typical cases of typhoid
fever. There were a few persons about the building and in
that vicinity, who did not drink the water, who did not have
the fever, but all that drank it had the fever. It was found
that the drinking-water that they used was from a well that
was about forty feet from a privy-vault that had been used
for ten years. We found that the contents of the privy-
vault had backed around into the well. The water tasted
good and had the appearance of being good water. At the
place there was an Artesian well that was one hundred and
forty feet deep carried into the building, but the students
and some of the teachers liked the surface well so much bet-
ter that they would go out from their rooms and down to this
well to get the water because they liked it. The deep well
was, of course, all right. I sent samples of this water to Dr.
Lattimer, of Rochester University, and he examined it and re-
ported that it was swarming with animalcula; and so 1 believe
that the large majority of cases of typhoid are the result of
drinking water that is contaminated by sewage and bad air, and
that in these cases of direct infection of typhoid fever there
is uo such thing as aborting them. These cases of continued
fever spoken of I should regard as a different disease from true
typhoid fever.
Dr. Bloomer. — Mr. President and Gentlemen : If this meet-
ing had been held a year ago Dr. Chapin would probably have
been here; and if he bad been here he would have, no doubt,
called attention to certain mental manifestations present in cases
of typhoid fever.
There is no doubt that about the third week of typhoid fever
there is a mental condition short of delirium, where the patient
600
DENISON: SEASONAL CLIMATIC MAPS OF THE UNITED STATES. [N. Y. Med. Jocb.,
is restless, apathetic, indifferent to his surroundings, when the
question of testamentary capacity often comes up. Dr. Chapin
related last year two cases published in the '■ American Journal
of Insanity."
In one of his cases the patient, fifty-eight years old, a
farmer, lying at the point of death, called his sons to his
bedside and discharged some obligations to the amount of
$6,000 or $8,000. He recovered from the fever ; and a year
afterward his sons were very much surprised by his asking
them to have this obligation discharged ; and he himself was
quite confounded when he learned that the instrument had
already been executed.
In another case the patient made a will in which he ignored
the heirs in the male line, and his signature bore such a striking
resemblance to that of the lawyer who guided the pen that
there was a contest over the will. The late Dr. Cook and Dr.
Chapin were called in as experts, who testified that in their opin-
ion the patient was non compos mentis, and not in a disposing
state of mind when he made the will; but the will was, not-
withstanding, admitted to probate because it was executed in
due legal form ; and you all know what objections lawyers raise
to the setting aside of an instrument that is executed according
to the legal requirements.
Dr. Elsner : I merely wish to say that possibly the title, as
it appears on the programme, is a misnomer.
The cases that I have described to you on paper have been
seen in this county, and my experience with typhoid fever has
bee'n limited to this county. We consider ourselves in central
New York, and, as I had no better name or title to give the
paper, I gave it the title that appears on the programme.
Now, in regard to roseola. I think that you will find, in
looking over the temperature-chart (for I have been particular
in marking the roseola), that it did usually occur between the
seventh and eighth day.
Then in regard to the abortive cases, and such cases as Dr.
Ross mentioned. We all see them.
We are all called to treat just such cases as the doctor has men-
tioned. Some of the patients have active delirium at once, and
some do not. We have a gradual rise of temperature, and, for a
few days, imagine that we have a well-defined case of typhoid
to treat; but our treatment is rewarded with success. Now,
those cases can not be considered typhoid fever. One of the
points that I wish to make in my paper is this: That we are not
justified in making the diagnosis of typhoid fever unless we are
sure that there are abdominal lesions. The tenderness in such
a case may be caused by many other things. Typhoid ulcera-
tion may cause tenderness ; ulceration in the region of the valve
may cause it, and many other diseases that are not typhoid at
all are associated with marked abdominal disturbance, yet can
not be considered cases of typhoid fever. If we speak of abort-
ing typhoid fever, such cases must be thrown out. We can not
consider those as aborting cases of typhoid.
In regard to the mental state. I did not mention that in my
paper, for I simply wish to impress upon your mind the leading
symptoms of typhoid as we see it.
Dr. Bloomer has mentioned the mental state in some cases
between the second and third week — that apathetic condition,
that condition when the patient does not care whether school
keeps or not. I think the much larger proportion of our patients
are just in that very condition at that stage of the disease. The
patient seems to lose all interest in himself or herself, however
solicitous he or she may have been before ; and I think there is
a stage in typhoid, though I would not make this as a positive
statement, at which these patients are not responsible for what
they do, however clear they may have been during the entire
course of the disease. I have repeatedly asked patients who
have appeared perfectly rational throughout the entire course
of the disease whether they remembered any facts concerning
their sickness ; much the larger proportion of them have told
me that the time during the entire sickness seemed as if it had
been a dream.
THE ANNUAL AND SEASONAL CLIMATIC
MAPS OF THE UNITED STATES;
WITH A RULE FOR THE EVEN DIVISION OP
CLIMATE,
BASED UPON THE AVERAGE OF THE COMBINED ATMOS
PHERIC HUMIDITIES IN THE UNITED STATES*
By CHARLES DENISON, M. D.,
DENVER, COL.
It is not the author's intention to write a new paper for
the Climatological Association this year, but simply to com-
plete his last year's contribution by a presentation of the
graphical illustration of climatic statistics and of the divis-
ions of climate in our own country, which was an important
part of his last year's report. He can thus fulfill his obli-
gation as " Committee on Climatic Elements, etc., Acting
with the Chief Signal Officer," for the maps which are pre-
sented contain the different condensations of nearly five
million signal-service observations, and for temperature,
rain-fall, and wind movements — all the records since the
Signal-Service stations were established. The result of
studying so broad an area as is included within the bound-
aries of the United States is very gratifying in the presen-
tation of a variety of climates and an amplitude between
the extremes of moisture and dryness such as can hardly
be claimed by any other government. Indulgence is craved
for the introduction of the following descriptions of these
climatic maps and the data they contain :
I. The Annual Map. — The annual map and tables are
intended to give all the desirable annual averages of climatic
statistics, and to graphically illustrate the most important
of these — i. e., the* cloudiness of the air, annual tempera-
tures, rain-fall, and wind — directions as to their prevalence
and their influence upon the weather.
Cloudiness. — The relative cloudiness of the sky is one
of the most important facts to be determined about the
climate of different sections, for it is an estimate of the
humidity of tbe atmosphere, which is but slightly affected
by local peculiarities and the unequal radiation from the
earth's surface. Particularly is cloudiness little affected by
those faults of temperature statistics in cities, which are
due to the greater heat there, and radiation from stone
buildings, paved streets, etc. Besides, it is the most accu-
rate estimate yet obtained of the duration of sunshine. The
Signal-Service Bureau has no other reckoning of the time
the sun shines than that obtained by inference — i. e., if the
sky is beclouded at two given stations thirty and sixty per
cent, of the time, then the sun is assumed as shining sev-
enty and forty per cent, of the time it is above the horizon
at those places respectively. The annual average of sun-
shine can, accordingly, be approximated at from less than
forty per cent, of day-time, in the northern Central Lake
* Read before the American Climatological Association, May 27,
1885.
Nov. 28, 1885.J DENISON: SEASONAL CLIMATIC MAPS OF THE UNITED STATES.
601
region of the United States, to more than seventy per cent,
along the eastern slope of the Rocky Mountains and in
southern Arizona. This is a reasonable conclusion, and in
accordance with the testimony of many observers. The
sunshine is, therefore, represented by one hundred per cent,
minus the per cent, of cloudiness of a"ny given section.
The proportion of cloudiness is telegraphed daily to Wash-
ington from all signal stations at 7 a. m., 3 p. m., and 11
p. m., Washington time. From these telegrams for the
year 1883 the percentages were obtained which are graphic-
ally illustrated by the color shades on the annual map.
They are divided into six grades of color, and show the
proportion of cloudiness to range from over sixty per cent,
of the time (one hundred being continuous cloudiness) to
less than thirty per cent. The exact per cents, for each of
the 136 signal stations are given in the tables, on the bor-
der of the map. It is interesting to note a somewhat inti-
mate relation between increased cloudiness and increase of
rain-fall and relative humidity, a fact which strengthens the
belief that cloudiness is a good index of atmospheric hu-
midity.
Temperature. — The average annual temperatures of belts
of country stretching across the United States are repre-
sented by the solid blue lines. These isothermal lines are
described by the figures (Fahrenheit scale) given at their
termini on either coast. They are computed, according to
the plan of the Signal Service, by dividing the sum of the
7 a. m., 3 and 11 p. m. observations by three to get each
daily record. These isotherms represent the average of
annual means for all time since the signal stations were
established (for dates of establishment see annual tables),
as do also the records given in the border tables for each
station. The temperatures of places between isothermal
lines can be approximately determined according to their
nearness to the same.
Rain-fall. — The amount of rain and melted snow is
accurately measured at each signal station (see Mean Pre-
cipitation in border tables), and the average yearly totals
are graphically illustrated by the interrupted blue lines run-
ning over the face of the annual map. The inches of rain-
fall are given at the termini of each of these lines on the
border of the map. The variations in rain-fall within the
boundaries of the United States are remarkable, being from
less than five inches in southeastern California and south-
western Arizona to over seventy inches on the coast of
North Carolina.
Winds. — An important part of the climatic maps to
agriculturists, and to those who wish to prognosticate the
state of the weather, is the record of the winds as to what
winds bring pleasant weather and what usher in rain. Be-
sides these two important facts, the prevailing direction
serves to show whether pleasant-weather winds or rain-bear-
ing winds are most likely to blow at any given place. All
these three records are given by the groups of arrows which
arc scattered over the United States, the groups represent-
ing the regions in the center of or near which they are, and
each kind of wind being indicated by a distinct form of
arrow. These winds are the averages for the year 1882,
and they blow as the arrows fly on the map, the quarter of
the earth's surface, from which the pleasant-weather or rain-
bearing winds come, being pretty nearly represented by the
spread of the arrow's feather. The velocity of the ivind at
every signal station is constantly determined by a self-regis-
tering anemometer, and this valuable record (since the
signal stations were established) is represented in the tables
at the border of the annual map by the miles per month
traveled by the wind. The comparative windiness is further
given as determined by these records. For instance, Pike's
Peak (1) is the windiest and La Mesilla (132) the least
windy of all the places where the records are complete for
the year, while the average for Denver, rating her as the
95th, shows that there are 94 out of 132 stations which are
more windy than the " City of the Plains."
Elevations. — The elevations given in the border tables
are the distances in feet, above sea-level, of the observation
stations of the Signal Service Bureau, and are approximately
accurate as representing the cities where these stations are.
On the annual map the approximate elevation of sections of
country are given which are over one thousand feet above
the sea.
Ranges of Temperature. — Those who make a great point,
as many do, of the precise variations of temperature, will be
interested in the means of maximum and minimum and
daily and monthly ranges of temperature, given in the border
tables. The means of the maximum and minimum tempera-
tures for 1883 are the averages of the daily highest and
daily lowest temperatures for all the stations. From these
two the mean daily range of temperature is computed,
which is also given. The average or annual mean of
monthly ranges of temperature is the average difference
between the highest and lowest records in each month, and,
with the daily range, indicates the equability or variability
of a given climate. Many physicians, who had hitherto
recommended equable climates for the classes of consump-
tives which can be benefited, have lately learned that varia-
bility is often to be preferred, as this quality pertains par-
ticularly to stimulating, dry, cool, and elevated climates,
while equability always accompanies enervating warmth
coupled with injurious dampness of atmosphere.
Relative and Absolute Humidities. — Relative humidity is
the per cent, of moisture the air holds to what it would con-
tain if it were saturated with vapor. It is always expressed
in hundredths (saturation being 100), and the annual aver-
ages for all the signal stations are given in the border tables.
A low average of relative humidity indicates the infrequency
of fogs or dews as well as the presence of other qualities, as
much sunshine and little rain, which produce a dry climate.
Absolute humidity is the real humidity of the air or the
weight of vapor to a given space. It is usually reckoned in
grains of vapor to the cubic foot of air. In the border
tables of the annual map the annual record for 1883 is
given in grains and hundredths, while in the tables of the
seasonal charts it is given in tenths of a grain of vapor to a
cubic foot of air.
Dew Point. — This is the temperature at which the air
will become more than saturated by the amount of vapor it
contains. The annual mean dew point, which is that given
in the border tables, is always lower than the given mean
602
DENISON: SEASONAL CLIMATIC
MAPS OF THE UNITED STATES. [N. Y. Med. Joob.,
temperature of a place. The reason is this : the air can
hold moisture according to its temperature, the range being
very great — i. e., from about one half a grain to the cubic foot
of air at zero to over nineteen grains at 100° F. Now, the
annual average of relative humidity never exceeds 90 per
cent., so the temperature must be lowered for dew to be
deposited. The explanation is similar considered with
reference to absolute humidity. A place which has four
grains of vapor to the cubic foot of air and a temperature
of 62° (66 per cent.) must have its temperature reduced to
49° when four grains will just exceed saturation. The
greater the difference between the mean dew point and
mean temperature of a place, the less frequently do fogs
occur.
Vapor Tension. — This is the elastic force of vapor, and
represents the expansibility of the vapor of water the air
contains. The moister the air, the greater is its elasticity
or pressure. This elasticity is determined by the difference
between the wet- and dry-bulb thermometers, and is ex-
pressed in hundredths of English inches (see border table
for annual means). This method of expression is used be-
cause the expansibility of the air, due to the vapor it con-
tains, is determined by the depression in inches of a column
of mercury when acted on by this force.
II. The Seasonal Charts. — The seasonal charts serve
a special purpose in presenting all important climatic data
in quarterly divisions, which method has many advantages
over the annual representation. In the annual statistics we
have not even approximate representations of either sum-
mer or winter, for, being on opposite sides of the mean for
spring and autumn, they neutralize each other when com-
bined, and the significance of each, is lost. The seasonal
division of the year is therefore necessary in order to show
the contrasts between winter and summer. It aids the mind
in retaining correct impressions of separate data, while a
semi-annual subdivision would be rather impracticable, and
monthly statements too confusing to be remembered. The
study of climate by seasons is the most satisfactory and the
most rational method for physicians, agriculturists, health
seekers, tourists — in fact, the great majority of those inter-
ested in climate.
Combined Humidities. — An important and peculiar ob-
ject of these seasonal charts is to illustrate a classification
of climates which the author has originated after much de-
liberation. It is that which is given in the blue and red
color shades, and is based upon an equitable combination of
the humidity statistics of the atmosphere for 1883. The
object being to rate all sections according to their records,
nearly a third the rating influence is given to each of three
attributes of climate, namely, cloudiness and relative humid-
ity per cent., and absolute humidity in tenths of a grain of
vapor to the cubic foot of air ; or, perhaps, more definitely,
about 35 per cent, to the first, 40 to the second, and 25 per
cent, to the third, in the order named. The object of this
rating is to correct the mistake of judging by any one evi-
dence of moisture or dryness. Cloudiness is uninfluenced
by the faults of temperature or absolute humidity records
taken in cities, and is comparatively independent of purely
local effects ; yet cloudiness is somewhat ot a relative quan-
tity, since the upper strata of the atmosphere must reach
saturation in order that clouds may exist. Relative humid-
ity would be an admirable test of atmospheric humidity
were it not so fickle and under the dominion of faulty tern
peratures and changing winds. Absolute humidity, how-
ever, is more st;lble. It is an actual, real statement of the
amount of atmospheric moisture, and serves as an excellent
means of correction for relative humidity. For instance,
Pike's Peak for spring, with a high relative humidity of
•84, has a low absolute humidity of nine tenths of a grain
of vapor because of its low temperature, 15° ; while Cedar
Keys, with a less relative humidity, '73, has a high abso-
lute humidity — five and seven tenths grains — because of its
high average temperature, 70°, for the same season. So
each of these factors corrects the faults of the other two,
and all of them combined better represent the climate of
the country than any one of them alone can do. The
finally accepted method of combining these statistics was
to rate every station, forward or backward, from the aver-
age, which was assumed as the middle of climate for the
United States. This mean of humidity statistics for the
year would be represented by the average of the dividing
lines between the blue and the red shades on the four charts.
It is this yearly average with which all places are compared,
those of more moisture being thrown appropriately into
the shades of moisture (blue), and those opposite into
shades of dryness (red). Since absolute as well as relative
humidity is dependent on temperature, the capacity of the
air to hold moisture varying according to temperature, it
became necessary to have a separate rating standard or
figure for each degree of temperature. Thus the " Rating
Table " and the " Rule of Moisture and Dryness" were con-
structed, which are given both on the summer seasonal chart
and on the annual map. The rating figures represent one
third the sum of the three rating factors, and with this a
third of the records of every place is compared. It must
be remembered that this is not a geographical mean ; so it
is not essential to accuracy that the moist half should ex-
actly correspond in area to the dry half. To get a fair
mean as the basis of the " Rating Table," the averages of
the separate factors were determined according to methods
of computation approved by those in authority to judge
of this subject. These means were found to be 44^ per
cent, for cloudiness, 67 per cent, for relative humidity, and
67 per cent, of saturation for absolute humidity, expressed
in tenths of a grain of vapor to the cubic foot of air. By
these standards combined the proper climatic rating of every
locality is determined, based upon the official and unbiased
records of the Signal-Service Bureau. Thus a much-needed
definition is obtained of what moisture and dryness mean
as applied to climates. The moist and dry halves are each
divided into four equal divisions, which are respectively
represented by the blue and red shades on the seasonal
charts. The seasonal peculiarities of localities and the rela-
tion of seasons to each other are thus well illustrated. In-
stance the large area (see winter chart) in the Northwest
and in the Northern Lake and Central River regions,
which are thrown into the solid blue shade of the ex-
treme of moisture by the cold of winter, and the equally
Nov. 28, 1885.1
SMITH: THE CONSTRUCTION OF SPRAY-TUBES.
large area (see summer chart) in the Southwest that is
thrown into the solid red shade of the extreme of dryness
by the heat of summer. Thus the laws which govern the
diffusion of heat and terrestrial radiation are at many points
illustrated by these charts. It is hoped this seasonal pre-
sentation of combined humidities will be appreciated, espe-
cially by those who would avoid undesirable weather in one
season by a temporary removal to a more genial clime.
( To be concluded.)
THE PRINCIPLES INVOLVED IN THE CON-
STRUCTION OF SPRAY-TUBES *
By ANDREW H. SMITH, M. D.
The Bergsen, or, as it is more commonly called in this
country, the Sass spray-tube, having practically superseded
all other forms, it is to this that attention will be confined
in this paper.
The instrument consists essentially of two tubes placed
one above the other, the upper one, which for brevity's sake
we will designate A, carrying compressed air or steam,
while the lower one, which we will call F, supplies the fluid
to be atomized.
The free extremities of these tubes, greatly diminished
in size, are so arranged in relation to each other that the
stream of air issuing from A passes at a right angle across
the tip of F. The action of the spray-tube depends upon
the fact that air possesses a considerable degree of adhesive-
ness, the different particles adhering to^each other with no
little tenacity.
We are familiar with this property in viscid fluids and
to a less degree in plain water, a drop of which can be
drawn along a table by the finger, but we are not apt to
think of it as belonging to the atmosphere or to gaseous
bodies. Yet it is owing to the fact that the air or steam
which escapes from A clings to and drags with it the air at
the extremity of F that a vacuum is produced in F. Into
this vacuum the fluid rises, and in its turn is caught by the
current from A and dispersed in the form of spray.
The greater the velocity of the air-jet escaping from A,
the greater will be the exhausting force exerted upon F,
and therefore the greater the efficiency of the atomizer.
As the velocity of the stream of air is greatest at its center,
A
where it is least retarded by friction, it follows that the axis
of the opening of A should be exactly on a line with the
extremity of F.
* Read before the American Laryngological Association, June 25,
1885.
The pressure being the same, the character of the spray
will depend upon the relative size of the openings of A and
F. Increasing the former permits more air to escape and
gives a larger volume of spray with a greater carrying force
and more power of penetration. Increasing the latter re-
sults in a larger consumption of fluid, forming a coarser
spray, and, if carried too far, results in dripping.
A large opening for A with a small one for F gives a
large body of very fine spray. A small opening for A with
a large one for F gives a small body of coarse spray. A
successful application of spray to the throat or to the pos-
terior nares often requires that it be effected as it were by
surprise, and before there is time for reflex action of the
muscles. Hence it is necessary that spray should be formed
the instant the air-valve is opened ; for, if the arrival of the
liquid at the point of F is delayed appreciably after air
begins to issue from A, reflex contraction will have been
excited by the contact of the air with the mucous surface
before any spray is produced. Now, no fluid will reach the
point of F until all the air in F is exhausted, and the amount
of air and the length of time required for its exhaustion
will be in proportion to the length and the caliber of the
tube. Hence these should be reduced to a minimum in
spray-tubes intended for making quick applications. And,
as there is nothing lost in any case by this construction, it
may as well be made the general rule for all tubes.
With a properly constructed spray-tube comparatively
slight air-pressure will suffice for all purposes. Increase of
pressure will compensate in a measure for defective con-
struction of tubes, but it brings with it its own inconveni-
ences, such as mechanical irritation of the surface to which
the spray is applied, waste of compressing power, etc.
The indications for the use of coarse or fine spray do
not come within the scope of this paper, and will vary in
accordance with the views of individual practitioners.
ALCOHOL IN THE
TREATMENT OF ACUTE AND CHRONIC
FORMS OF ALCOHOLIC MANIA.
By LEWIS D. MASON, M. D.,
CONSULTING PHYSICIAN TO THE INEBRIATE HOME, PORT HAMILTON, N. T.
While in certain forms of neuroses, occurring in cases
of alcoholism, alcohol in any form would be injurious, nev-
ertheless there are conditions in which the judicious use of
alcohol is not only beneficial, but curative and indispensa-
ble, and its place can not be taken by other drugs. The
assertion that alcohol is only and always a poison, and must
not be tolerated in any condition, especially where the ine-
briate is concerned, is not carried out by our experience in
the class of cases to which we shall presently refer. The
indiscriminate and therefore injudicious and harmful use of
alcohol is not here indorsed ; we now speak of its careful
administration, where the quantity and form used arc regu-
lated by a competent practitioner. An asylum experience
of over nineteen years, embracing the eases of several thou-
sand inebriates, has given us ample opportunity to test the
relative value of sudden and complete abstinence from all
alcohol, and the plan of gradual reduction, or what is Lnown
601
MASON: ALCOHOL IN ALCOHOLIC MANIA.
[N. Y. Med. Jotjh.,
as the " tapering-off " system. And just here it is legiti-
mate to reason from analogy. Our experience has also em-
braced many cases of the opium and morphine habits. In
a few of the earlier of this class of cases under our treat-
ment the drug was left off abruptly. The terrible suffering
and collapse that ensued demanded the immediate restora-
tion of his full dose to recover the patient from a state of
suffering, if not peril, and the endeavor by some other and
less severe method to relieve him of the habit.
The same holds true in degree in certain cases in regard
to alcohol. The inebriate, whose nervous system is broken
down by his excesses, is suddenly deprived of his accustomed
stimulant. Some hours may pass and nothing worthy of
note happen; but in time the symptoms of deprivation mani-
fest themselves, and he pleads for his usual draught, and will
resort to all kinds of deceit or force to obtain it. He fails
by reason of his environments, and then mental aberration,
muscular tremor, insomnia, and the familiar symptoms of
delirium tremens are established. This is the common ex-
perience of the hospital surgeon. The habitual inebriate,
struck down by some accident, is brought into the hospital
ward. He is thus suddenly deprived of all stimulants, and
the necessity for administering the same is not recognized.
A few hours pass, sleeplessness ensues, and a case of deliri-
um tremens, associated with surgical injury, is established.
And the hospital surgeon could not meet with a worse com-
plication, especially in certain forms of injury, such as frac-
ture, where perfect rest is so essential to secure proper results.
During the first few years of our experience at the Ine-
briate Home at Fort Hamilton the " cut-off plan " from all
alcoholic stimulants was conscientiously adopted. Eecogniz-
ing the great evil that alcohol had done, we did not desire
to place it on record as of any use at all ; and, further, the
popular cry that inebriate asylums " were nothing more than
hotels for the accommodation of a certain class who desired
to continue their evil habits " influenced us somewhat to
adopt this plan.
Cases of delirium tremens were common. Hardly a
person entered the asylum but he was expected to pass
through his attacks of acute delirium. At present this is
an exception to the rule. If a patient enters the asylum,
and is at all tremulous, especially if he has had a long, tire-
some journey, and the experience of a sleepless night and
deprivation from his accustomed stimulant, he is regarded
as on the verge of an attack of delirium tremens, and the
judicious administration of a few bottles of ale, or its equiva-
lent in some other form of alcohol, given at proper intervals,
will not only quiet him, but tone up his nervous energy and
arrest a condition rapidly tending to delirium.
Many enter who do not need such treatment. The peri-
odic dipsomaniac who is on the tail-end of his spree and
is ready, after a day or two of rest, to again enter upon
his sober interval, will probably not need such stimulant.
The person most likely to demand it is the habitual inebriate,
because, of the two, the nervous- system of the latter is the
most shattered, and because, also, he is accustomed to a
daily stimulant. It must not be inferred that, in our asy-
lum, alcohol is improperly, indiscriminately, or irregularly
given. On the contrary, it is dispensed with as much care
and caution as other drugs. A record of the quantities
given, and the periods at which they are administered, in
each case is kept, as well as the effect upon the pulse, tem-
perature, and general condition of the patient. As a pro-
phylactic or abortive treatment for delirium tremens, I
know no remedy so safe and so potent as alcohol properly
administered. I believe that insomnia is more readily over-
come, and the end desired more promptly attained, than if
we attempted to secure the same result by large doses of the
bromides, chloral hydrate, or other hypnotics, and the risk
that attends the use of these drugs avoided. If we have
occasion to use these drugs also, less will be necessary, so
that the quantities used may be administered in safer doses.
I do not hesitate to assert that, by the too free use of these
drugs in cases of delirium tremens, in the effort to overcome
the persistent insomnia, the convalescence of the patient has
been greatly retarded, and life has been put in jeopardy and
even sacrificed.
The method, then, of administering alcohol should be
regulated by the condition of the patient. On the first
appearance of sleeplessness, mental aberration, muscular
tremor (and these should be watched for in all cases sub-
mitted to our care), a bottle of Bass's ale may be given
every two, three, or four hours, lengthening or shortening
the interval as the case demands, and then, after sleep is
obtained and the patient reacts from his mental irrationality
and physical depression, the use of the stimulant be sus-
pended.
The use of a stimulant may be necessary for a day or
so, or longer periods. We find it rarely necessary to con-
tinue it longer than a week or ten days, gradually decreas-
ing the quantity, and at the end of that time total abstinence
may be safely practiced for an indefinite period. I have
seen several instances, both in private and asylum prac-
tice, where the judicious use of ale alone, without other
medication, has arrested in a few doses the tendency of the
patient to acute delirium, and restored him to a safe condi-
tion of sleep and mental soundness. And, even in cases
where the delirium was marked and the insomnia persistent,
the judicious use of stimulants has put the patient on the
road to recovery. Ale will often succeed where whisky or
other forms of alcohol do not answer. After a night or two
of rest, the mental and physical condition of the patient
meanwhile improving, we may begin reduction and carry it
on as speedily as the case seems to warrant, and in a few
days the patient will be convalescent. If the case is one
accompanied by severe injury, it may be well to continue
the stimulant until the period of debility or shock has passed,
or the exhausting drain on the system has been arrested.
In chronic alcoholic dementia — a low type of mental
alienation occurring in alcoholics — the patient is ansemic,
listless, and full of delusions ; hears voices, and holds conver-
sation with imaginary persons ; appears to have sane moments,
but readily relapses into his old delusions ; his appetite is ca-
pricious, his sleep irregular, and his physical strength poor;
he moves about in a waking nightmare, he walks in a land of
dreams and shadows. The judicious use of stimulants in
these cases, a glass of ale at each meal and at bed-time, con-
joined with tonic treatment, proper diet, and regular exer-
Nov. 28, 1885.J
O'DWYER: TUB AGE OF
TEE GLOTTIS IN GROUP.
605
cise, will do much good. The use of bromides and chloral
to overcome the insomnia will only add to the already pro-
found mental disturbance and still further lower the physic-
al ione. I have already referred to the fact that the too
free use of the bromides and chloral and other depressing
drugs in the acute forms of alcoholic delirium may plunge
the patient into the more protracted forms of mental aliena-
tion to which the inebriate is particularly prone. I have
endeavored to be cautious in presenting my views ; but our
experience at the Fort Hamilton Asylum will not permit
me to indorse the idea held by some practitioners — viz., that
no harm can result from leaving off at once alcoholic stimu-
lants in any case, and that no good can result from continu-
ing them in any case of alcoholism ; that their use is not
only productive of mischief to the patient, but is, besides, a
great shock to the moral sense of the community. I main-
tain, however, that, if, by the judicious use of alcohol in such
quantities and at such times as we may direct, we can arrest
the onset of an attack of alcoholic delirium, or abbreviate
the duration of the more chronic forms, the result of the
treatment certainly warrants its adoption. In order that
my statements need not be misapplied or misconstrued, it
may be necessary to state that there are many persons who
drink alcohol in some form habitually, but never to excess
or intoxication, and who have not passed through the terri-
ble ordeal of delirium tremens, chronic alcoholism, or chronic
alcoholic mania, and who have not yet been convulsed with
alcoholic epilepsy. To such my remarks do not apply.
These persons are not inebriates in the true sense of the
word. Immediate and abrupt cessation with them means
nothing more than the leaving off of a very pernicious
habit, which, if continued, will carry them into the terrible
precincts of the inebriate. All such I most earnestly advise
to leave off alcohol at once. Total and immediate absti-
nence is their only safety.
Nor do we hold that all patients entering the Inebriate
Asylum demand the treatment herein indicated. But I wish
to impress the fact that a certain class of cases require alco-
hol in some form as a part of their treatment, and that in
these cases it is especially indicated. We all recognize the
moral side of the question ; but, when a life is wavering in
the balance, we must use the means which experience has
proved to be the best.
One of the best and most conservative authorities in
this special department of medicine indorses the judicious
use of alcohol, if not directly, at least indirectly, and comes
somewhat to our aid on this point. Speaking of digitalis
and its effects in large doses in the treatment of delirium
tremens — doses of half an ounce or an ounce of tincture
of digitalis — he writes : " The patient must have received so
much proof spirit;" and he is puzzled to account whether it
was the alcohol or digitalis that effected the good result,
and, although opposed to alcohol, says the favorable issue
was either due, probably, in the large number of suc-
cessful c ases, to a spontaneous favorable termination of the
disease, or was slightly helped by the alcohol which is
contained in the tincture ordinarily employed. The " cut-
off" plan is also considered by the writer; but he says
it is more diflicult to carry out this plan with older patients
. . . accustomed to depend for a long time on strong
drink as a large part of their nutrition. " But still,"
he writes, " we ought to try less harmful drugs — opium, In-
dian hemp, etc. — before resorting to so doubtful a remedy
as alcohol." Again : " Alcohol, also, in diminishing doses,
does seem to aid in the cure of feebler cases. If a man
has been drinking a quart of whisky daily up to the time
of his attack, a pint or quart of ale or porter will be to
him only a mild tonic beverage, aiding his digestion."
And, finally, the author is forced to this admission : " The
popular idea of tapering off is not altogether devoid of
scientific, as well as clinical, foundations." *
Another point to note, and of some value in gaining the
confidence and sustaining the courage of the patient in the
ordeal that he is to pass through, is the fact that his stimu-
lant will not be immediately " cut off" if it is necessary to
administer it.
I have no doubt that many persons desirous of entering
a special asylum for the treatment of their diseased appe-
tites would do so if they did not dread the sudden depriva-
tion from their accustomed stimulant. When a patient is
brought to our asylum, his first and only question often is,
"Will they cut me off at once?" This thought is upper-
most in his mind, intensifies his desire, and aggravates his
nervous apprehensions.
If we can, by the judicious use of a stimulant, carry
him over the first few days of his asylum experience, quiet
his fears, secure to him rest, and gain his confidence, we
have brought him successfully over the first part of his
treatment, and, in all probability, arrested a train of nervous
phenomena that would, if allowed to go unchecked, have
precipitated him into an attack of acute delirium, or per-
mitted him to drift into the more chronic form of alcoholic
mania.
TWO CASES OF CROUP
TREATED BY
TUBAGE OF THE G-LOTTIS.
By JOSEPH O'DWYER, M. D.
A brief account of my experiments in the treatment of
croup by tubage of the glottis, with illustrations of the
tubes and other instruments used, was published in the
" New York Medical Journal " of August 8th last. I have
since devised a much better extracting instrument than any
previously tried, and also made some slight modifications
in the tubes.
Since preparing the article above referred to, I have
treated two cases of croup, both of which occurred in the
service of Dr. C. C. Lee at the New York Foundling Asv-
i
mm. They were carefully observed and complete records
kept by Dr. Dillon Brown, the house physician :
The first case was that of Albert L., aged three years and
three months, who had a rather mild attack of diphtheria be-
ginning on July 9th, which was unattended by very serious
symptoms until the night of the 12th, when the voice became
husky anil the characteristic croupy cough began. During the
following day there was a moderate amount of dyspnoea, which
* Dr. Francis Edinond Auntie (Reynolds's " System of Medicine ").
606
O'DWYER: TUBA GE OF THE GLOTTIS IN GROUP.
[N. Y. Med. Jooh.,
increased during the night and became severe early on the
morning of the 14th.
Emetics, inhalation of steam, and hot poultices to the throat
gave only temporary relief. When I was called, at 3.30 p.m.,
the dyspnoea was so extreme that I introduced a tube immedi-
ately, and without difficulty, the time occupied by the opera-
tion, after the gag had been inserted, not exceeding ten seconds.
It gave rise to a vigorous spell of coughing which lasted at in-
tervals for about half an hour, during which a considerable
quantity of muco-purulent secretion was expectorated. After a
quiet and very natural sleep, lasting almost two hours, he drank
half a goblet of milk with a teaspoonful of brandy, which was
swallowed with very Utile difficulty. Temperature in the axilla
101-9°, pulse 140, respiration 30.
15th— Slept almost continuously during the night, looks
well, and is quite cheerful. Asks for drink in a faint whisper.
Some bronchial rales over the chest posteriorly. No membrane
visible in the pharynx. Temperature 99'3°, pulse 144, respiration
30.
16th. — Passed the night very comfortably. Suffers greatly
from thirst, owing to the extreme heat of the weather. Vom-
ited several times during the day in consequence of having taken
too much milk. Ordered cracked ice and iced Vichy, to allay
thirst, and milk to be limited to three pints in the twenty-four
hours.
18th. — Passed the two preceding nights very comfortably,
sleeping most of the time. Coughs very little, except when
drinking. Temperature 100-9°, pulse 160, respiration 35. The
afternoon temperature, taken for the first time in the rectum,
was found to be 103-5°. Removed the tube at 3p. m., ninety-six
hours from the time it was inserted. For a short time the
breathing remained perfectly free, and the cough, which in-
creased when the tube was removed, for a while retained its
tubal character, but soon became croupy again, and the ob-
struction returned so rapidly that I was obliged to reinsert it at
4.30. Has passed only about one ounce of urine in the last
twenty-four hours, which contained a considerable amount of
albumin and blood-corpuscles, but no casts. Given infus. digi-
talis with acetate of potassium, and hot poultices applied over
the kidneys.
19th. — Spent a very restless night. Vomited and had sev-
eral loose passages. Temperature 102-9°, pulse 168, respiration
42. Nothing found on auscultation but bronchial rales.
20th. — Passed a more comfortable night. Urine increasing
in quantity ; vomits occasionally. Temperature 102°, pulse 156,
respiration 40. Removed the tube at 2-30 p. m., and was obliged
to replace it at 4 p. m.
21st. — Slept almost the whole night. Excessive thirst con-
tinues. Temperature 101-9°, pulse 144, respiration 24. Sat up
sevei-al hours and was quite playful.
22d. — Removed the tube for the third time at 2.45 p. m., and
had to replace it in an hour and a half. Temperature 103°,
pulse 156, respiration 36.
23d. — Temperature 102°, pulse 132, respiration 36.
24th. — Tube removed at 11 a.m. and reinserted at 11 p.m.
Temperature 101°, pulse 138, respiration 30.
25th. — Removed the tube for the fifth time. Cough soon be-
came croupy, but without any marked dyspnoea during the day.
26th. — Did not sleep so well as usual. Some dyspnoea.
Temperature 103°, pulse 160, respiration 42.
A careful examination of the chest revealed nothing but
bronchial rales. Although the dyspnoea was not marked, the
tube was reinserted, with immediate improvement in all the
symptoms. The pulse fell to 130 and the respirations to 26.
The tube was finally removed on the 28th. The cough con-
tinued croupy with some elevation of temperature for several
days subsequently, but convalescence was uniriternipted. Urine
found free from albumin, August 4th, for the first time. lie
was sent out to board soon after, and I did not see h*m again
until October 30th, when his voice was perfectly restored. I
learned from his foster-mother that complete aphonia persisted
for about four weeks after his removal from the asylum.
The tube used in this case was two inches and an eighth
in length, and of much smaller caliber than the tracheal can-
nula in common use. It is quite probable that the long
continuance of the obstruction — fourteen days (the longest
time in any previous case being ten days) — was due in some
degree to oedema of the tissues of the larynx, superinduced
by the nephritis.
The second case was that of John E , aged sixteen months,
always a pale, delicate child, who had a severe attack of diph-
theria, beginning on October 10th. There was extensive pseudo-
membranous deposit in the pharynx, with marked swelling of the
tonsils and severe constitutional disturbance. The first symp-
toms of croup appeared on the 13th, and I was called at 2 p. m.
the following day. The breathing was then very much ob-
structed and noisy, with marked recession of the sternum and
lower ribs during inspiration, but no restlessness nor other evi-
dence of suffering. The swollen tonsils, still partially covered
with membrane, had an excavated, sloughy appearance, and the
surface of the body was extremely pale ; even the lips had no
color. Temperature 102°, pulse 198, respiration 28.
As the case was absolutely hopeless, I concluded to resort to
tubage only in case of severe suffering. I was called again at
5 p. m., and found him extremely restless and evidently suffering
very acutely. I inserted a tube one inch and three quarters long
with some difficulty, as there were no double teeth to hold the
gag, and it was difficult to keep the mouth well open. The
relief to the dyspnoea was complete, the pulse soon fell to 160,
and his general condition was for a time considerably improved.
He took milk and brandy in sufficient quantity, but did not
swallow so well as the preceding patient.
15th. — Passed the night in a fairly comfortable mariner.
Early in the morning the temperature was 104-5°, pulse 192,
respiration 54; 2 p.m., respiration 70, pulse and temperature
about the same. Bronchial rales, of all kinds and in great pro-
fusion, heard everywhere over the chest, while the resonance
was not impaired. Death took place, without much apparent
suffering, at 5 p. m. , twenty-four hours after the tube was in-
serted.
At the autopsy, six hours after death, the lungs, which re-
ceded normally when the chest was opened, were found per-
fectly normal, there being neither emphysema, atelectasis, nor
even an abnormal amount of blood in them. A thick deposit
of pseudo-membrane was found in the larynx, trachea, and
bronchial tubes, as far as the third or fourth division, the cali-
ber of the right and left bronchus particularly being reduced to
a very small size. The tube, which was perfectly clear, reached
within about half an inch of the bifurcation. The right heart
contained a well-washed clot.
In the majority of the fatal cases of this disease, after
obstruction in the upper air-passages has been overcome, it
is difficult to exclude incipient pneumonia, owing to the
presence of more or less congestion and atelectasis; but in
such cases as the one just recorded, and I have notes of
several similar cases, the high, temperature and accelerated
breathing, in the absence of anything else to account for
them, must be attributed to the extension of the diphtheritic
process into the bronchial tubes.
Nov. 28, 1885.|
BOOK NOTICES.
607
Dr. Waxhain, of Chicago, who procured a set of my
tubes early in the present year, recently reported five cases
of croup treated by this method. Dr. Brush, of Mount Ver-
non, has also used them in two cases.
858 Lexington Avenue.
Doctrines of the Circulation. A History of Physiological Opin-
ion and Discovery in regard to the Circulation of the Blood.
By J. 0. Dalton, M. D., Professor Emeritus of Physiology
in the College of Physicians and Surgeons, New York, and
President of the College. Philadelphia : Henry C. Lea's Son
& Co., 1884. Pp. 296.
This little work, as its title suggests, is largely historical.
Beginning with Aristotle, the idea of the circulation is traced
step by step to the school of Alexandria, through the period of
the Renaissance to the age of Fabricius, and finally to the time
of Harvey.
Although an unassuming hook, it shows evidences of a vast
amount of research. Many curious and interesting facts are in-
troduced from the works of the older writers, and in an appen-
dix (including upward of fifty pages) there are numerous Greek
and Latin citations. The book is a valuable one, not only to
the special student and lover of the quaint and curious, but to
the general medical reader.
Lectures on Phthisis Pulmonalis. Delivered at the Detroit
Medical College, Detroit. By Ernest L. Shurly, M. D.,
Professor of Laryngology and Clinical Medicine, Detroit
Medical College, President of the American Laryngological
Association, etc. Detroit: George S. Davis, 1885.
In this little volume of about a hundred pages Professor
Shurly has given, with admirable clearness and brevity, an in-
structive resume of our present knowledge of the subject of
pulmonary phthisis. To this he has added the results of a wide,
intelligent, and carefully digested personal experience. The
treatment of phthisis and its complications is considered with
great thoroughness, and this department, occupying as it does
about one half of the book, will be read with unusual interest
and profit.
A Practical Treatise on Fractures and Dislocations. By Frank
Hastings Hamilton, A. B., A. M., M. D., LL. D., Late Pro-
fessor of Surgery in Bellevue Hospital Medical College, and
Surgeon to Bellevue Hospital, etc. Seventh American Edi-
tion, Revised and Improved. Illustrated with three hun-
dred and seventy-nine woodcuts. Philadelphia: Henry C.
Lea's Son & Co., 1884. Pp. xxxi-1005.
It is unnecessary to repeat the words of commendation
which have so often been used with reference to this work,
which has now become classical. The present edition is fully
up to date, the alterations and additions being suggested, as the
author says, by recent journal articles. He acknowledges his
indebted ness for new material to Dr. Stimson, of New York,
and Dr. Poinsot, of Paris. The treatise is eminently practical ;
indeed, it is the author's purpose throughout to avoid empty
theories, and to introduce only such facts as have stood the test
of clinical experience. It is with no small feeling of pride that
an American points to " Hamilton on Fractures and Disloca-
tions" when the originality of his countrymen is called in ques-
tion. Such works as this, embodying the results of the prac-
tice of several generations of medical men, redeem us from the
charge of superficial work, and prove that, whatever may be
the failings in our system of medical education, practical inge-
nuity and common sense are not wanting with us.
BOOKS AND PAMPHLETS RECEIVED.
The Pedigree of Disease: being Six Lectures on Tempera-
ment, Idiosyncrasy, and Diathesis, delivered in the Theatre of
the Royal College of Surgeons, in the Session of 1881. By
Jonathan Hutchinson, F. R. S., late Professor of Surgery and
Pathology in the College, etc. New York: William Wood &
Co., 1885. Pp. 113.
A Text-Book of Nursing, for the Use of Training-Schools,
Families, and Private Students. Compiled by Clara S. Weeks,
Graduate of the New York Hospital Training-School, etc.
New York : D. Appleton & Co., 1885. Pp. 396. [Price, $1.75.]
Manual of the Diseases of Women, being a Concise and Sys-
tematic Exposition of the Theory and Practice of Gynaecology,
for Use of Students and Practitioners. By Charles H. May, M.
D., late House Physician, Mt. Sinai Hospital, New York, etc.
Philadelphia : Lea Brothers & Co., 1885. Pp. xi-25 to 357, in-
clusive.
Official Formulas of American Hospitals. Collected and
Arranged by C. F. Taylor, M. D., Editor of the "Medical
World." Philadelphia: The "Medical World," 1885. Pp.238.
[Price, $1.]
Diseases of the Larynx. By Dr. J. Gottstein, Lecturer at
the University of Breslau. Translated and Added to by P.
M'Bride, M. D., F. R. C. P. E., F. R. S. E., etc. Edinburgh and
London: W. & A. K. Johnston. Pp. 274.
Post-mortem Examinations, with Especial Reference to
Medico-legal Practice. By Professor Rudolph Virchow, of the
Berlin Cbarite Hospital. Translated by T. P. Smith, M. D.. M.
R. C. S. E., with Additional Notes and New Plates. From the
Fourth German Edition. Philadelphia: P. Blakiston, Son, &
Co., 1885. Pp.138. [Price, $1.]
On the Tests for Muscular Asthenopia, and on Insufficiency
of the External Recti Muscles. By Dr. Henry D. Noyes, of
New York. [Reprinted from the "Transactions of the Eighth
Session of the International Medical Congress."]
Tracts on Massage. No. II. The Physiological Effects of
Massage. Translated from the German of Reibmayr, with
Notes, by Benjamin Lee, A.M., M. D., Ph.D., etc. Philadel-
phia, 1885. Pp. 46.
The Therapeutics of High Temperatures in Young Children.
By William Perry Watson, A. M., M. D., Jersey City, N. J. [Re-
printed from the " Archives of Paediatrics."]
Observations on the Cause and Treatment of Infantile Ecze-
ma and Allied Eruptions. By Henry T. Byford, M. D., Chicago.
[Reprinted from the "Journal of the American Medical Associ-
ation."]
Letters from a Mother to a Mother on the Formation,
Growth, and Care of the Teeth. By the Wife of a Dentist,
Mrs. M.W.J. Philadelphia: Welch Dental Company, 1885.
Pp. 106. [Price, 25 cents.]
Report on Ophthalmology. By A. M. Wilder, M. D., etc.
[Reprinted from the " Transactions of the Medical Society of
the State of California."]
The Causal Relation of Obstructed Cardiac Circulation to
Lymph Stasis. By Samuel C. Busey, M.D., Washington. [Re-
printed from the " American Journal of tho Medical Sciences."]
Primary Lateral Spinal Sclerosis. By J. B. Marvin, M. !>.,
etc. Read before the Kentucky State Medical Society, June 26,
1885.
608
LEADING ARTICLES.
[N. Y. Mkd. Jodb.
THE
NEW YORK MEDICAL JOURNAL,
A Weekly Revieiv of Medicine.
Published by Edited by
D. Appleton & Co. Frank P. Foster, M. D.
NEW YORK, SATURDAY, NOVEMBER 28, 1885.
WHAT MAY COME OF A SUIT FOR DAMAGES.
Our readers need not be told — for those of them who have
loDg followed the practice of medicine are painfully aware of
the fact — that medical men are peculiarly subject to injustice at
the hands of the law. As one of our English contemporaries
has lately remarked, the very institution that ought to be an
unfailing and readily available refuge for any man who is con-
scious of his rectitude — the law — is becoming more and more a
remedy worse than the disease, if not an engine of oppression.
"He who filches from me my good name steals that which not
enriches him, but makes me poor indeed," may many a man
of our craft exclaim when he finds himself in its toils. Whether
he has been goaded to seek redress in the law, or has been made
against his will to take a position that subjects him to the gihes
of every loafer who reads the vulgar newspaper accounts of
things medical, he is lucky if on any such occasion he can look
back on the affair, after all is over, with more satisfaction than
regret.
If this can be said of the legal entanglements to which physi-
cians are ordinarily and everywhere liable, what will be thought
of a state of things in which obedience to the law is the very
act that leads to punishment? This is what seems to have been
exemplified recently in New York? One of the ordinances of
the sanitary code makes it incumbent on physicians to notify
the Health Department of cases of infectious disease, and they
are subject to a heavy fine for any neglect to do so. Several
years ago Dr. A. E. M. Purdy, an esteemed practitioner, gave
notice to the Health Department, under this regulation, that,
in his opinion, a young woman who was under his treatment
was suffering with small-pox. Thereupon the Department sent
one of its medical officers to visit the patient, and it appears
that he agreed with Dr. Purdy as to the nature of the case, and
the woman was removed, contrary to her will, to a public hos-
pital set apart for infectious diseases. Her sickness proved to
be of short duration, and she was not long detained, but she
has now brought suit against Dr. Purdy for damages, alleging
that the business in which she was engaged has been seriously
injured by the fact that her old customers, having learned of
her misfortune, shunned her shop ; and, further, that Dr.
Purdy's diagnosis was erroneous, since she did not have small-
pox, but simply a dermatitis of the face, caused by a prepara-
tion containing acetic acid having accidentally come in contact
with it. She sued for ten thousand dollars damages, and last
week a jury awarded her five hundred dollars.
We can scarcely regard this verdict in. any other light than
as a miscarriage of justice. In the first place, Dr. Purdy still
maintains the correctness of his diagnosis. It is in evidence
that the sanitary inspector agreed with him, and he certainly
seems to us to have been entitled to any doubt that might arise
in the attempt to establish a retrospective diagnosis. It is to
be borne in mind, too, that Dr. Purdy is a gentleman of mature
experience, familiar with the clinical picture of small-pox and
fully alive to the considerations that always restrain prudent
men from condemning patients to the odium and discomfort
involved in public information of their having such a disease,
until they can no longer avoid that course. A jjriori, then, the
assumption that the diagnosis of small-pox in this case was in-
correct would seem to rest upon a very slim foundation.
But, allowing that it was incorrect, it ia difficult to see the
equity of holding the physician responsible for the misfortunes
that happened to the patient in consequence of that diagnosis
having become known. The notification to the Health Depart-
ment was merely the expression of an opinion on the part of a
man whom the law compelled to express his opinion. The
Health Department did not rest satisfied with that opinion, but
sent one of its own inspectors to examine into the facts. The
information upon which the patient's removal from her home
was decided on came, therefore, not from the physician in at-
tendance, but from the Department's own officer. The straight-
forward interpretation of these facts would seem to relieve Dr.
Purdy of all responsibility in the case.
We have heard it said that Dr. Purdy was sued in this case
because a suit could not be brought against the Health Depart-
ment. If the Department is really hedged about by such a
divinity, it seems to us that the sooner it is removed the better.
It is notorious that heretofore the reports of infectious diseases
to the Board of Health have been exceedingly defective ; what
will they be henceforth, since it is virtually proclaimed that
whoever reports a case does so at his peril ? The Board has
been lenient in inflicting penalties, so lenient as recently to
have called forth severe criticism from a well-known citizen,
and we lately took the trouble to offer certain excuses in its
behalf. In the light of the verdict in the Purdy case, we
doubt if any amount of leniency on the part of the Board, in so
far at least as concerns reports of cases of infectious disease,
will not be countenanced and even insisted on by the commu-
nity. Should the case become a precedent, our registration of
infectious diseases will practically cease to be founded on any-
thing else than such cases as the sanitary inspectors may stum-
ble upon, for our medical practitioners will surely choose to
risk having to pay a specified sum, however onerous it may be,
rather than incur the danger of being mulcted still more heavi-
ly. Small-pox will then be "given a fair chance," and every-
thing will be lovely.
THE COUNTY SOCIETY AND THE CASE.
An extraordinary piece of business came before the Medi-
cal Society of the County of New York at the meeting held
last Monday evening, being none other than the consideration
of the suit in which Dr. Purdy was lately the defendant, and in
which the jury brought in a verdict of damages in five hundred
dollars against him. The main features of the case were those
that wo have set forth in the preceding article.
Nov. 28, 1885.]
MINOR PARAGRAPHS.
609
Associations for the legal defense of medical men are not
unknown abroad, and, in the absence of any such organization
in this community, we know of no good reason why the county
society should not on occasion assume such a r61e. We are
glad, however, that the meeting was prudent enough not to
engage in a discussion of the way in which the further conduct
of Dr. Purdy's defense should be carried on, in case of appeal,
but contented itself with empowering the Comitia Minora to
take such action in the matter as it might deem best.
We trust that the Comitia will act more carefully about the
affair itself than it seems to have acted in preparing what was
probably meant to be a notification that this particular business
would come before the meeting. "Shall the medical profes-
sion," says the notice, " be subjected to a penalty of five hun-
dred dollars for reporting contagious diseases to the Health De-
partment of this city ? " We hope that we shall hear of no
more instances of individuals being mulcted on such grounds,
and we are quite confident that " the medical profession " will
not be so mulcted ; and, if damages are again awarded in such
a case, we do not know that it will necessarily be in the sum of
five hundred dollars. But the Comitia "means well."
MINOR PARAGRAPHS.
HE REPORT OF THE SURGEON-GENERAL OF THE NAVY.
The report for the year ending September 30, 1885, is not a
long document, for it makes only a pamphlet of seven pages.
It states that the appropriations for the repairs of hospitals have
been so small that the Bureau has not been able to maintain
.hose institutions in a satisfactory condition, and that the fur-
ther reduction for the current year may cause serious embarrass-
ment. The Surgeon-General is, therefore, compelled to ask for
an increased appropriation for the coming year, in order to
maintain the establishments in the necessary state of preserva-
;on. He calls attention anew to the bad condition of the drains
of the hospital inclosure at Portsmouth, N". H. The quarantine
'emporary hospital lately built on Widow's Island, in Penobscot
Bay, has been inspected by the Surgeon-General, and he reports
that its construction is satisfactory, and that he saw no evi-
dences of any feeling of anxiety among the residents of Rock-
nd or North Haven about the risks of disease being introduced
om ships that might visit the station. He considers it a safe
nd desirable refuge for infected vessels from the West Indies
or the Gulf of Mexico. One hundred and seventy-eight articles
have been added to the Museum of Hygiene, and eight hundred
nd thirty books to the library.
MORE NEWSPAPER MEDICINE.
One of the daily newspapers lately published a long dispatch
from Cleveland, O., setting forth the wonderful features of a
case of triple gestation, in which one of the children was born
several days after the two others, and of a case of dermoid cyst.
There is usually a lurking suspicion that the physicians in attend-
ance are in some measure answerable for newspaper articles of
this type, but we are quite ready to absolve the accoucheur from
the charge of having connived at the publication of such a state
of things as happened in the first case.
NEWS ITEMS, ETC.
The New Jersey Sanitary Association held its eleventh
annual meeting in Trenton on Thursday and Friday of last
week.
Infectious Diseases in New York.— We are indebted to
the Sanitary Bureau of the Fourth Division of the Health De-
partment for the following statement of cases and deaths re-
ported during the two weeks ending November 24, 1885 :
DISEASES.
Week ending Nov. 17.
Week ending Nov. 34.
Cases.
Deaths.
Cases.
Deaths.
3
0
2
2
25
8
33
9
21
0
39
9
Cerebro-spinal meningitis. . . .
4
4
3
3
13
4
17
5
59
28
72
23
7
2
7
2
The Woman's Hospital. — The annual meeting of the man-
agers was held on Thursday of last week. The receipts were
reported as less by $1,514.33 than those for the year before.
The Regulation of Medical Charity.— The conference
held last week between members of the Charity Organization
Society and representatives of several of the public medical in-
stitutions was well attended, and resolutions favoring the exten-
sion of the society's system to the various institutions were
passed. A committee of conference was appointed, consisting
of Mr. Hewlett Scudder, Mr. A. B. Ausbacher, Dr. S. 0. Van
der Poel, Dr. J. W. Roosevelt, and Dr. J. H. Emerson.
A Death from Yellow Fever is reported to have taken
place at the Chambers Street Hospital last Sunday, the patient
having been a fireman on a steamship which is said to have
passed Quarantine the Thursday before and been reported as
free from sickness. The vessel had touched at several ports in
the West Indies.
The Edinburgh Infirmary.— The "British MedicalJour-
nal" learns that Mr. Skene Keith has been appointed a special
assistant in his father's (Dr. Thomas Keith's) ward.
The Academy of Medicine in Ireland. ^The "Medical
Times and Gazette " states that Dr. Thomas Addis Emmet, of
New York, has been elected an honorary fellow of the Academy.
The Death of M. Bailliere, the founder of the well-known
Paris medical publishing house, is announced as having taken
place last Saturday. He had reached the age of eighty-eight
years.
The Death of Dr. William Frothingham.— On Thursday'
of last week Dr. Frothingham, a well-known physician of Wash-
ington Heights, was killed by the discharge of a pistol which
he had undertaken to put in order for the purpose of killing a
sick dog. The deceased was fifty-five years old, and had prac-
ticed at Washington Heights for twenty years. He was a mem-
ber of several of the larger medical societies of New York, and
was much esteemed in the profession.
Army Intelligence. — Official List of Changes in the Sta-
tions and Duties of Officers serving in the Medical Department,
United States Army, from November 15 to November 21, 1885 :
Heoer, Anthony, Major and Surgeon, member of the Army
Medical Examining Board now in session in New York city,
is relieved from the additional duty of attending surgeon in
that city, to take effect when Joseph R. Smith, Lieutenant-
Colouel and Surgeon, shall have arrived in New York and
entered upon that duty. S. O. 267, A. G. O., November 19,
1885.
Elbeet, F. W., Captain and Assistant Surgeon. Sick leave of
absence further extended six months on surgeon's certificate
of disability. S. 0. 263, A. G. 0., November 14, 1885.
610
LETTERS TO
THE EDITOR.
[N. Y. Med. Jolu.,
Strong, Norton, Captain and Assistant Surgeon. Relieved
from duty at Fort Union, New Mexico, and ordered for duty
as attending surgeon, Headquarters, District of New Mexico,
and post surgeon, Fort Marcy, New Mexico. S. 0. 171, De-
partment of the Missouri, November 16, 1885.
Ewing, C. B., First Lieutenant and Assistant Surgeon, now
at Fort Leavenworth, Kansas, ordered to proceed to Fort
Reno, Indian Territory, and report to commanding officer
for temporary duty in the field. S. O. 170, Department of
the Missouri, November 13, 1885.
Marine-Hospital Service. — Official List of Changes of
Stations and Duties of Medical Officers of the United States
Marine-Hospital Service, for the week ended November 21, 1885.
Yemans, II. W., Passed Assistant Surgeon. Promoted to be
Passed Assistant Surgeon from November 1, 1885. Novem-
ber 14, 1885. Reassigned to duty at San Francisco, Cal.
November 16, 1885.
McIntosh, W. P., Assistant Surgeon. Appointed an Assistant
Surgeon. November 14, 1885. Assigned to duty at New
Orleans, La. November 16, 1885.
Society Meetings for the Coming Week :
Tuesday, December 1st: New York Obstetrical Society (pri-
vate) ;J New York Neurological Society ; Elmira, N. Y.,
Academy of Medicine ; Buffalo Medical and Surgical Asso-
ciation; Ogdensburg, N. Y., Medical Association; Medical
Societies of the Counties of Herkimer (semi-annual — Herki-
mer), and Saratoga (Ballston Spa.); N. Y. ; Hudson County,
N. J., Medical Society (Jersey City) ; Androscoggin County,
Me., Medical Association (Lewiston).
Wednesday, December 2d: Medical Society of the County of
Richmond (Stapleton), N. Y. ; Penobscot County, Me., Medi-
cal Society (Bangor).
Thursday, December 3d : New York Academy of Medicine ; So-
ciety of Physicians of the Village of Canandaigua, N. Y. ;
Boston Medico-Psychological Association ; 'Obstetrical So-
ciety of Philadelphia.
Friday, December l^th: Practitioners' Society of New York
(private).
Saturday, December 5th: Clinical Society of the New York
Post-Graduate Medical School and Hospital ; Manhattan
Medical and Surgical Society (private); Miller's River, Mass.,
Medical Society.
fetters to tbe (goitor.
THE GRENET CELL VS. THE CHLORIDE-OF-SILVER CELL
FOR A PORTABLE GALVANIC APPARATUS.
156 Madison Avenue, October 24, 1885.
To the Editor of the New York Medical Journal:
Sir: While perusing a file of Journals which had accumu-
lated during the summer months, my attention was caught by
an article in your Journal of July 18, 1885, from the pen of
Professor L. C. Cray, entitled "Two Valuable Aids in Electro-
Therapeutics." As the subject was one which bore upon a field
in which for some years I have been extremely interested and
quite actively employed, I feel it my duty to correct some state-
ments made in that article apparently on insufficient informa-
tion. The article in question is written (evidently with great
enthusiasm) in support of a portable galvanic battery made of
chloride-of-silver and zinc elements, which (according to the
author) so far surpasses all previous efforts of electricians that
he says : " I am prepared to say that its general employment will
mark a new era in galvano-therapy."
Now, let us see upon what facts the champion of such a re-
markable invention (as this would seem to be) rests his claim
for its universal recognition. If I should state in the commence-
ment that I have intentionally omitted this form of cell from the
list of those which I have depicted and recommended in my
forthcoming work upon Electricity in Medicine," and that I
have done so for good and sufficient reason, I must either admit
myself to be unacquainted with the progress lately made in
electrical devices, or I must prove the soundness of my convic-
tions. I prefer to attempt the latter.
The chloride-of-silver and zinc element as the basis of a bat-
tery is not new. Dr. Gray need not have written to foreign
countries (as he states in his article that he has done) to obtain
much valuable information respecting its rise and fall. The
"chloride-of-silver battery" presented to the profession some
years since by the Western Electric Company is practically the
same as the one Dr. Gray now extols. True, it had glass cups
in place of rubber ones (which cost more), and it lacked some
other of the mechanical features described by Dr. Gray, although
the latter are but copies or slight modifications of identical de-
vices employed by other manufacturers of this city and of Europe.
Its excitant was the same, the elements were the same, the cell
was practically the same, and the battery was light and easy to
handle (the only claim, in my opinion, which it ever had to
" universal recognition ").
This battery was sold extensively at first by a reputable firm
jn this city, and probably equally so elsewhere. This firm final-
ly declined to continue selling it, and I am informed that the
Western Electric Company has since discontinued its manufac-
ture. So much for the history of the "chloride-of-silver bat-
tery " in this country from a practical standpoint. Dr. Gray
admits that a Mr. Schoth, of Europe, has thus far failed to make
a satisfactory battery with this form of cell — although he has
been " experimenting with them at Dr. De Watteville's instance."
Dr. Gray has tried his own battery but a few months; yet, be-
cause it works and is light, he gives it his unqualified indorse-
ment. Is not the conclusion on its face rather a hasty one?
In the second place, this type of cell has a low electro-motive
force, and generates but a small quantity in the battery Dr.
Gray describes. The elements are costly, and are not regarded
by well-posted electricians as possessing the durability Dr. Gray
claims for them. It is true that tbe silver can be reclaimed
(when the fluid is saved after the elements are consumed and
subjected to certain chemical processes), but few physicians
would go to that trouble for the purpose of saving a few dollars.
Dr. Gray estimates that it will cost "about $8 per year" for
repairs. Even at this very low estimate, the battery becomes
decidedly expensive. He fails, moreover, to state the first cost
of the instrument — so that comparison on that score with the
cost of other batteries made by reputable manufacturers is im-
possible.
In the third place, great stress is laid by Dr. Gray upon the
light weight of the battery (9 to 12 pounds). Personally, I fail
to see why a physician who owns a buggy and horse need to
care much if a few pounds of weight are or are not dispensed
with, provided that he can carry the machine easily from the
carriage to the house of each patient without assistance. With
a portable battery composed of the Grenet cells he gains (1)
cheapness of construction; (2) a fluid which can be renewed
when required at a cost of a few cents; (3) a cell whose ele-
ments last a long time and cost about ten cents each to replace
when they at last are consumed by the fluid; (4) a high electro-
motive force ; (5) a considerable quantity of electricity — if the
elements are of the usual size; (6) an easy way of overcoming
Nov. 28, 1885.|
polarization when the battery is in use; (7) a clean instrument
which, when properly made, will not spill the fluid : (8) the
ability to select the cells employed from any part of the battery ;
and (9) a simplicity of construction which admits of repair by
the physician himself if he possesses a screw-driver and a pair
of pinchers.
Some months ago Dr. Brown, of this city, exhibited, at a
meeting of the Clinical Society of the New York Post-Graduate
Medical School, the very battery which Dr. Gray now presents
as novel. The remarks of Dr. Brown were published, without
the cut, in the "New York Medical Journal" in February,
1885. If I am not mistaken, Dr. Brown had been instrumental
in calling the attention of the manufacturer to several of its
best features.
Io closing, I would say that the sentence in Dr. Gray's arti-
cle which impugns the many advantages claimed for the Grenet
cell, both by myself and others, for a portable galvanic appa-
ratus, is not in accord (as far as I can learn) with the expe-
rience of thousands who are to-day using this form of cell in
Europe and this country. It seems to give universal satisfac-
tion when properly managed and cared for.
Respectfully yours,
A. L. Ranney, M. D.
A NEW ANTISEPTIC LIGATURE.
Jersey City, October 19, 1885.
To the Editor of the New YorTc Medical Journal:
Sir: Ligatures have been used for many years for bringing
together and retaining solutions of continuity, also for the liga-
tion of blood-vessels. They have been made from a number of
materials, such as silk, linen, catgut, silver and iron wire. Phy-
sicians prefer one or the other, as their experience or judgment
may dictate. Claims have been made for this or that particular
ligature, in some cases, as being superior to the others.
In solutions of continuity the principal points of a good liga-
ture are ease of application, a ligature that will hold when
properly applied, and of a non-irritant character, so that it can
be left in the wound as long as necessary — *. e., until the edges
adhere, without exciting undue inflammation. Silk for ligatures
has been used more than any other material, and, as a rule, has
answered the purpose; but, after a few days in the tissues, it
absorbs moisture, causing pus to form, which provokes a dis-
charge from the wound, and thereby tends to prevent, in some
cases, union by first intention. Before the silk is used it is
coated with bees-wax, to keep it firm and prevent the thread
from slipping in the surgeon's hand. I have for some years used
shoemaker's wax for coating silk ligatures, which is highly anti-
septic, and can be left in the wound wmuch longer time than by
using bees-wax. To show the antiseptic nature of shoemaker's
wax, I will give you the composition as obtained from an intel-
ligent shoemaker, who has made it for himself and others:
Rosin 1£ lb., pitch 1 lb., melted together in a vessel over the
fire; remove and then add half a pound of Archangel tar (com-
mon); the whole to be mixed to a proper consistence. As I
consider this an improvement on the usual method of coating
ligatures with bees-wax, and am not aware of its having been
used for this purpose, I wish to make it known through your
journal. James Craig, M. D.
THE NAMES OF THE ENCEPHALIC ARTERIES.
Ithaca, N. Y., October 24, 1885.
To the Editor of the New York Medical Journal :
Sir : The report of my paper On a Seldom-described Artory
(A. terrnatica), with Suggestions as to the Names of the Principal
Encephalic Arteries, in the "Transactions of the American
Neurological Association," pp. 33, 34 ("Journal of Nervous
611
and Mental Disease," vol. xii, No. 3, pp. 348, K49, July, 1885)>
contains an error, due to my own inadvertence, which can be most
effectually corrected if you can spare the space for the following
table, as amended. Instead of two cerebellar arteries, there are
three, superior, anterior, and inferior, the mononymic new
names for which are pra'cerebellaris, medicerebellaris, and post-
cerebellaris, and the English paronyms of these, precerebellar,
med {cerebellar, and postcerebellar.
Common Latin naines.
Proposed names.
English paronvms.
Abbrevia-
tions.
Vertebralis.
Basilaris. (02.)
Cerebellaris superior.
Cerebellaris anterior.
Cerebellaris inferior.
Cerebralis anterior.
Cerebralis media.
Cerebralis posterior.
Communicans anterior, (az.)
Communicans posterior.
Choroitlea anterior.
Choroidea posterior.
Vertebralis.
Basilaris.
Pracerebellaris.
Medicerebellaris.
Postcerebellaris.
Prsecerebralis.
Medicerebralis.
Postcerebralis.
Praecommunicans.
Postcommunicans.
PriEchoroidea.
Postchoroidea.
Vertebral.
Basilar.
Precerebellar.
Medicerebellar.
Postcerebellar.
Precerebral.
Medicerebral.
Postcerebral.
Precommunicant.
Postcommunicant.
Prechoroid.
Postchoroid.
vrtb.
bslr.
prcbl.
mcb'.
pcbl.
prcb.
mcb.
pcb.
picm.
pcm.
prchrd.
pchrd.
I have no mononym to propose for the very awkward dio-
nymic eponym, Circulus Willisii (circle or pentagon or hexa-
gon of Willis), but one is certainly desirable.
In this connection, permit me to add that in the paper On
Two Little-known Cerebral Fissures, following the one just
named, on pages 350 and 351, neutromesal, callossal, and hypo-
catnpal, should be ventromesal, callosal, and hippocampal. and
on page 352 hippocampal should be included with the "fissures
mainly or partly mesal." B. G. Wilder.
North Brooklfied, Mass., November 18, 1885.
To the Editor of the New York Medical Journal:
Sir: Are not the numerous remedies dispensed by druggists
becoming a serious usurpation of physicians' practice? I re-
quested a druggist to keep on hand a preparation of bromo-caf-
fein, which I wished to prescribe for headaches, which, by the
way, is an excellent remedy in the beginning of a sick head-
ache. I now fear that my opportunities for prescribing the
remedy are lessened, as I doubt not the druggist recommends it
to others, who otherwise would apply to a physician. Ought
not the druggists to be informed through their journals as to
their duty in this matter, or shall physicians, as the evil in-
creases, have to dispense their own medicine in self-defense?
Very respectfully,
J. Garst, M. D.
firoceeijings of Societies.
NEW YORK ACADEMY OF MEDICINE.
Meeting of November 19, 1885.
The President, Dr. A. Jacobi, in the Chair.
A Section in Laryngology. — A motion looking to the estab-
lishment of a Section in Laryngology was adopted.
The Health Department. — A letter from Mr. James Gal-
latin was read by the secretary, by which it appeared that the
Board of Health of New York city had asked for a considerable
increase in the annual appropriation over that for last year,
whereas the amount allowed by the commissioners fell very con-
siderably below that sum. In view of this fact, there was danger
of the efficiency of the board being crippled by the reduction of
the salaries of those who did the principal work. He Imped the
Academy would exert its influence toward lopping oil' sinecures
PROCEEDINGS OF SOCIETIES.
612
PROCEEDINGS
OF SOCIETIES.
[N. Y. Mud. Jour.,
and toward Laving nuisances corrected without the additional
expense attending repeated inspections by the health authori-
ties.
Dr. Gouverneur M. Smith had nothing to say with regard
to the wisdom of reducing the appropriation called for, but
with regard to other points brought out in the letter he thought
we should speak, and therefore offered the following resolu-
tions :
Whereas, It is a generally recognized fact that the value of
the work of the Health Department of the City of New York
depends largely upon the presence therein of competent medical
men, and,
Whereas, It has been declared expedient that some reduction
should be made in the expenditures of the department during
the coming year ;
Resolved, That it is the sense of the New York Academy of
Medicine that said reduction should be effected in such a way
as not to impair the usefulness of the department either hy the
dismissal of any of the competent and experienced physicians
now in its service, or by lowering their salaries below a fair and
equitable rate.
Dr. Fordyoe Barker thought there was nothing in the
spirit of the letter, nor in the spirit of the resolutions, which
would not be for the best interests of the medical profession.
As to how far the expenditures might have been injudicious,
and how far the appropriations might be diminished, he was
not able to speak, but there was no doubt that for the interests
of all concerned the board should secure the services of physi-
cians of integrity and ability, and then see that they were amply
paid. He seconded the resolutions, and they were adopted
without a dissentient voice.
The Annual Address: Pathfinding in Medicine. — Dr.
Henry D. Noyes then read the anniversary address. He had
been impressed with the thought that further advancement in
medicine must depend upon acute, exact, and deep research.
Clinical observation had done much toward advancing medical
knowledge, and it promised still to do good work in the form
of collective investigation, but it must be supplemented by work
in the laboratory. Indeed, he laid greatest stress upon the im-
portance of laboratory research, and instanced the discoveries
made by Virchow, Helmholtz, Pasteur, and others. The value
of exact and deep research made by some persons of restricted
opportunities had been well illustrated in the case of that bril-
liant scholar, Dr. Thomas Young, to whom the author paid a
warm tribute of respect. He also paid a tribute of honor to
Mr. Palmer, who overcame all obstacles and finally succeeded
in becoming master of Oriental and other languages, which was
turned to practical U9e in winning the friendship of desert tribes
which had harassed the workers on the Suez Canal. But to
build and equip a laboratory for scientific investigation involved
a large outlay of money. It was for this reason that in Europe,
where governments built and sustained laboratories, and paid
professors who had risen to eminence in special departments of
their profession for taking charge of them, more numerous dis-
coveries had been made, especially in bacteriology. If the
people of this country, and especially the wealthy people of
New York, were made to see the need of opportunities for exact
research in order to advance the health interests of the human
race, many would be found who would contribute of their
wealth toward the building and equipment of laboratories.
Proof of this view already existed in the munificent gift of Mr.
Vanderbilt to the College of Physicians and Surgeons, and in
the building of the Carnegie Laboratory.
Dr. Fordyce Barker spoke of the pleasure with which he
bad listened to anniversary addresses before the Academy of
Medicine many years ago, but more recently, on account of the
inefficiency, he said, of Dr. Jacobi's predecessor, the custom had
been dropped and had not been revived until the present year.
He was glad that the president had renewed it, and moved
that a vote of thanks be extended to the orator of the evening.
The motion was unanimously carried. Dr. Barker expressed
great hope that ere long the Academy would be able to supply a
laboratory for use by those engaged in special investigation.
Surely a city having so many wealthy people as New York
would not allow this need to be long felt.
NEW YORK SURGICAL SOCIETY.
Meeting of November 10, 1885.
The President, Dr. Robert F. Weir, in the Chair.
Neuralgia of the Superior Maxillary and Inferior Den-
tal Nerves; Resection; Cure.— Dr. William T. Bull present-
ed a man showing the results of two operations — one per-
formed upon the superior maxillary, and the other upon the
inferior dental nerve— for obstinate neuralgia. These operations
had been performed fifteen months before, .and, as there had
been no return of the trouble whatever, he thought the case
might be regarded as one of cure.
A night watchman, sixty-two years of age, was admitted to the New
York Hospital July 29, 1 882. For several years he had had at inter-
vals some pain in the right side of the face, which within a year had
become more severe and almost continuous. He was rheumatic, had
not had syphilis, and the history of malarial disease was doubtful. All
sorts of medical treatment had been resorted to, and many teeth in both
the upper and the lower jaw had been extracted. When admitted he
was suffering from the same pain, which was partly controlled by hypo-
dermic injections of morphine. There were tender points over the in-
fra-orbital and mental foramina, and over the condyle of the jaw. He
was slightly emaciated, and could not eat solid food, and also had pain
in talking.
August 11, 1884- — The superior maxillary was exposed in the floor
of the orbit and three fourths of an inch removed. The artery was
divided and bled sharply. It was stopped by a plug of catgut which
was continuous, with a few strands emerging from the center of the
wound. Peat and bichloride dressing were applied. The wound healed
primarily in four days.
18th. — The inferior dental nerve was exposed by a vertical incision
over the ramus of the jaw and by chiseling through the outer wall of
its canal (Warren's operation). The incision was placed low enough to
avoid Stenson's duct ; the fibers of the masseter, with the periosteum,
were raised with the elevator, and the upper angle of the wound was
strongly retracted. It was a narrow wound to work in, but there was
little difficulty in removing a rectangular piece of bone, one fourth by
three fourths of an inch in area. Three quarters of an inch of the
nerve were removed. In separating it from the artery the latter was
wounded and tied with catgut. A small bone-drain was left in the
wound, which was treated like the other. At the end of a week, when
the dressing was removed, the wound had healed except at the orifice
of the tube, and this closed promptly under an iodoform scab.
From the time of the operation the man experienced no pain
whatever in the face, and there was complete anaesthesia over
the areas supplied by the nerves. There was no facial paralysis.
Now, fifteen months after the operation, he continued perfectly
well. There had been a dull aching in the lower jaw in damp
weather, but it was trifling in degree, and did not increase in
either frequency or sj verity.
Dr. R. W. Amidon had kindly examined the man lately, and
stated : " I tested the sensibility with a faradaic current and a
single-wire electrode, and found complete anaesthesia on the right
side of the face over an area included between two lines running
from the outer and inner angles of the orbit downward to the
line of the chin. It does not reach far back on the cheek, or
Nov. 28, 1885.J
PROCEEDINOS OF SOCIETIES.
613
much under the chin. It does not reach the lower palpebral
margin, nor quite to the median line on the nose. In the lips and
chin it extends exactly to the median line. It involves the gums
and what teeth there are in the lower jaw on the right side up
to the median line. At the outer, upper, and nasal borders of
the area the anaesthesia shades off into normal perception. On
the lips and chin the anesthesia is complete up to the median
line, and the transition to normal sensibility is sudden. There
is no anaesthesia of the palpebral conjunctiva of the right lower
lid or the right internal canthus, or the gums of the upper jaw,
or the tongue. There is no paralysis of any facial muscle. He
has complained of his sight being weak since the operation. I
find the fundus normal and the vision good, but with the prism-
test I find that he has an insufficiency of the interni (probably
the right) of 5° for distant vision and 12° for near vision, and he
reads much better with a prism to correct that.
" Query : Did you injure, during the operation, the branch
of the inferior division of the third nerve which passes under the
optic nerve to the right internal rectus? "
The President said there was one point worthy of special
note in Dr. Bull's case, and that was the extremely satisfactory
result from an operation performed externally instead of divid-
ing the inferior dental and maxillary nerves within the mouth.
He thought the internal section, made after Paradacini's method
at the spine of Spix, was rather an unsatisfactory operation. It
was somewhat difficult to perform, and the amount of nerve ex-
tracted was comparatively limited.
Dr. F. M. Markoe said he had had a satisfactory result in a
similar case, but the operations were not performed at the same
time. Quite a number of years ago he operated upon a patient
who had suffered for a long time and severely with neuralgia in
the parts supplied by the inferior dental nerve. He trephined
the canal and cut out about one inch of the nerve, and with per-
fect success. About three years afterward the patient came to
him with neuralgia of the superior maxillary nerve, and he per-
formed the same operation, cutting out about one inch of the
nerve, going hack to the point where it entered the antrum,
and destroying the nerve as far hack as was possible with the
point of the scissors, and again with success which lasted a little
more than two years, when the patient returned witli some
slight neuralgia affecting the region supplied by the supra-
orbital nerve. The man was unwilling to undergo further opera-
tion, and disappeared from observation. Up to that time, how-
ever, covering a period of five or six years, he had experienced
perfect relief.
Remarks on Excision of the Hip.— Dr. L. M. Yale then
read a paper with this title. [See page 593.]
Dr. Markoe said the paper was so statistical in character
that there was hardly room for discussion, and that it contained
an extremely interesting and very valuable accumulation of re-
sults obtained by different operators. So far as he had been
able to discover, nothing appeared in the paper which indicated
that the danger of tubercular infection was either greater or
less in those operated upon than in those not operated upon.
Dr. Yale said that was the conclusion, except in this one
instance. Caumont had analyzed all the cases treated in every
way, between one and two hundred in all, and drawn the con-
clusion that tuberculosis was in no way relieved by exaction ;
indeed, one third of the patients died after excision, and one
fifth in suppurative cases without exsection. Of course that
was not a sufficiently large number of cases to settle the ques-
tion.
The President asked if we were not premature in laying
much stress on general infection after an operation upon a
tuberculous hone or joint, as it was a matter which had not
been brought to our notice, especially with reference to later
pathological developments, until within the last two or three
years. He wouid feel unwilling to accept such statements as
conclusive until a- larger experience had been obtained. This
inference, if received as final, would cut off all attempts at oper-
ative interference for the purpose of getting ahead of tubercu-
lous disease in bones and joints, and would render such opera-
tions unjustifiable.
Dr. 0. T. Poore thought that private statistics should not be
put in comparison with hospital statistics, because statistics de-
rived from patients among the better classes were more favor-
able to the expectant plan of treatment. He did not believe
that statistics of excision of the hip joint in hospital cases in
general would show more than 33 per cent, of mortality, and in
the same class of children treated expectantly without operation,
his impression was, the mortality was greater than after exci-
sion. He was unable to see how one could determine, while
persistent suppuration existed, whether or not he had to deal
with simple caries of the joint or with a sequestrum which
could not be removed without, an operation. Besides, it was a
serious question whether many patients with extensive disease
of the acetabulum would ever get well without au operation,
and whether an operation in those cases would remove that
source of danger.
Dr. F. Lakge thought it generally conceded that a compara-
tively large percentage of patients with hip-joint disease would
entirely recover under proper conservative treatment without
excision of the joint. Even extensive destruction of bone did
not preclude spontaneous recovery and a comparatively good
functional result. He had observed so much destruction of
bone that at last the trochanter was considerably above Nela-
ton's line, still without noticeable suppuration, and at the end
with some mobility and a very useful limb. He thought it so
much a point of experience as to whether in a given case one
should follow out conservative treatment, or resort to more
radical interference, that only the long-continued observation
of a large material might entitle us to draw general conclusions.
He must say that, as a principle, he was rather inclined to push
the conservative treatment as far as possible, and his impression
was that, even in cases presenting a more serious aspect, if only
all the indications of hygiene and orthopaedy were fulfilled, and
retention of pus prevented as much as possible, good results
could be obtained. Further, he thought that, if by consequent
general treatment one succeeded in altering in a favorable way
the constitution of the patient and in checking the progress of
the local tuberculous process, any kind of surgical interference
would he followed by more satisfactory results so far as com-
plete recovery was concerned. Though feeling conviuced that
small particles of necrosed bone might be absorbed by the action
of vigorous granulations, it was beyond doubt that a large per-
centage of patients would not recover entirely unless tubercu-
lous sequestra were removed. Hence eventually in these cases
excision had to be considered. He had repeatedly tried to avoid
total excision, and to perform more of a sequestrotomy, but he
must say that in all the cases but one he had been obliged to
add excision of the upper end of the femur in order to get suffi-
cient access to the diseased parts to enable him to remove with
some degree of certainty the structures involved. In the one
case above mentioned, in which several tubercular sequestra
were removed from the anterior aspect of the acetabulum with-
out touching the head of the femur, except to scrape away quite
an amount of granulations, healing apparently took place, but
it had not been under observation a sufficient length of time
to enable him to determine whether recovery was permanent.
He regarded the necessity of removing so much bone in exci-
sion of the hip joint as a great drawback to the operation, and
did not think that the amount of shortening was so little as was
614
PROCEEDINGS OF SOCIETIES.
[N. Y. Med. Jouk.,
generally assumed. The question, what was the amount of
shortening in adults who at an early age had been subject to
excision of the hip joint, was not settled yet, and was worthy
of careful investigation. Suppose we had a young patient with
tuberculous osteitis of the acetabulum, and we removed, as
might become necessary, a large portion of that bone, besides
the separation of the shaft of the femur above the trochanter
minor. In such a case we might have three or more inches of
bone in its length lost, and, in addition to that, have abolished
what additional growth might have come from the preservation
of the upper epiphyseal cartilage. One ought to state how
much that represented in the adult, in order to fix more accu-
rately the question of indication for total exsection. The latter
would of course always exist where the operation had to be
done as a means of preserving life, and he thought that the
standpoint of a good many surgeons and orthopaedists, as a mat-
ter of principle, not to do any exsection at all, was identical
with sacrificing a certain number of lives which otherwise might
be saved. Especially the results of orthopaedists were not abso-
lutely conclusive, because in the majority of the worst progres-
sive cases the patients did not apply to them, or eventually gave
up their treatment in order to search for some more speedy
relief. Regarding the very important question of functional
result, he was not able to give a decisive answer. He had had
some very good results after excision, and other cases in which
after excision recovery was incomplete, or the functional result
deficient. He had observed in several cases where a great por-
tion of the acetabulum had had to be removed, in spite of con-
sequent abduction during the after-treatment, that the shaft did
not find a favorable point of support. One was able to make
out in such cases a certain amount of slipping of the bones
against each other, according to the more or less strong and
tense fibrous connection; and he must further say that he was
not convinced yet that, under all circumstances, a patient with a
movable joint after excision was better off than one with anky-
losis in good position. The latter, with a slight amount of flex-
ion, would always have a safe gait, and was not deprived of the
advantage of being able to sit. Besides, his limb would proba-
bly not be so short as that of the former, who, to be sure, might
occasionally offer an excellent result, at other times an incom-
plete one. He also thought one point worthy of attention,
namely, whether the position of the limb after excision, as well
as after conservative treatment, was a lasting one. Eventually,
after a year, perhaps after a good many years, an unfavorable
position might take place. He had once within the last seven
years seen general tuberculosis follow excision of the hip, appa-
rently caused by the operation. The latter was done at an early
stage of the disease. There were several sequestra belonging
to the head of the femur, and the patient died, in the third
month after the operation, of tubercular meningitis.
Dr. Yai.e said, with regard to the amount of shortening
which might occur, that, according to Ollier's experiments, if
it was assumed that the growth from the upper epiphysis was
absolutely abolished, it was possible that, with the ordinary
growth from that extremity of the femur, about nine centi-
metres might be lost. To that there might be added the atrophy
from inactivity. He had measured many cured patients, some
of whom had had abscesses, and others none, with regard to the
different sources and amount of shortening. He had seen a
tibia in a coxalgic person fall behind one inch or more, and it
was fair to presume that the diminution in the growth of the
femur was quite as much. If that was added to the other, it
was possible that several inches might have been lost from sim-
ple inactivity. The amount of functional use which a limb
might have with ankylosis after an extensive disease of bone
had recently been brought to his mind by the case of a patient
who, fifteen years before, had come under his care with an ab-
scess which had been totally neglected. There were many fis-
tula), and in the spring of 1871 he contemplated excising the
joint, and asked the opinion of Dr. Sayre, who said that excision
would do but little good on account of the great amount of dis-
ease of the pelvic bones. He therefore treated the case as best
he could without resorting to operative interference, and the
patient recovered with ankylosis, and was now a teacher in one
of the public schools, although she still had six sinuses about
the hip, which discharged more or less. The limb was in very
good position ; the actual shortening in the femur was an inch
and a quarter, in the tibia about one inch, which is partially
compensated for by tilting of the pelvis, and the remainder is
nearly made up by super-extension of the sound limb; and
practically, therefore, she walks with a shortening of only about
half an inch, and locomotion is with only a very slight limp.
He also recalled the case of a young man who. after he was
cured, had thirteen cicatrices about the hip, and he was, when
last seen, able to take an active part as a member of a baseball
club.
A Urinary Calculus spontaneously fractured in the
Bladder. — Dr. J. C. Hutchison presented a specimen which
had been removed by bilateral lithotomy from a man twenty-
three years old, who gave the history of stone in the bladder
beginning when he was five years old. His general health was
excellent, and he had always been able to attend to his business
without much suffering until he began to drive a cart in the
city of New York, when he experienced considerable pain in
the bladder after a long day's drive over rough stones. Three
weeks before he applied for treatment his symptoms suddenly
grew worse, and the pain was so great that he was compelled
to give up work. On exploration of the bladder with a searcher,
the speaker at once detected a calculus. An instrument had
never before been introduced into the bladder. Bilateral lithoto-
my was performed, and the two fragments of stone shown
were removed. The patient made a satisfactory recovery. The
surface of the stone showed no marks of an instrument with
which it might have been broken, and the fractured surfaces
were not covered with urinary deposits or smoothed by attri-
tion, showing that the fracture was quite recent. All the evi-
dence went to prove that the fracture was spontaneous, that it
was the result of forces acting from within, and that it occurred
at the time there was a sudden increase of pain in the bladder —
three weeks before the operation. The stone was composed of
calcium oxalate, with a uric-acid nucleus. It weighed 859
grains, was disc-shaped, measured an inch and a half in its
transverse and an inch in its vertical diameter, and its surface
was smoothly mammillated.
Dr. Ord,* in a paper read before the London Pathological
Society, had expressed the opinion that there were three meth-
ods by which a calculus might spontaneously fracture: 1. From
forces arising within the calculus itself; "in an altered state of
the urine the nucleus becomes swollen, and acts as a bursting
charge in a shell." 2. From molecular disintegration. 3. From
weakness of the layers within the crust, allowing its fracture.
The speaker could not understand how either of these methods
could have caused the fracture in this specimen, nor had he any
satisfactory explanation to offer.
Dr. Hutchison also presented twenty-two calculi removed
by median lithotomy from a gentleman sixty-six years old, on
on whom he had performed litholapaxy two years before. They
varied in size from that of a pea to that of a hazel-nut; the sur-
faces were fissured, but not rough, and of a light-red color. A
section of one was made for examination. It was composed
* "British Med. Jour.," May 10, 1879, aud September 1, 1878.
Nov. 28, 1885.]
PROCEEDINGS OF SOCIETIES.
615
mainly of uric acid, with a small amount of calcium phosphate.
The total weight when removed was 478 grains. The patient
recovered, but died some time afterward from causes not con-
nected with the bladder. The speaker also showed the frag-
ments removed from this patient two 'years before by rapid
lithotrity. They weighed 225 grains, and were composed of
uric acid and calcium oxalate.
Dr. Poore presented two small calculi removed from a child
who was operated upon in May last by median lithotomy. The
child was three years and a half old, and the second operation
had been performed in September last.
The President asked if the child had suffered very much
after the first operation.
Dr. Poore replied that the father, although perhaps his'
statement could not be accepted without allowance, had said
that the child suffered a great deal after it left the hospital
where the first operation was performed. At the time of its
discharge after the last operation the child had no bladder
symptoms.
The President said he had asked the question because it was
well known that in the old subject two stones not infrequently
existed and escaped detection. One case he recalled particularly,
in which the patient was operated upon by the late Dr. Van
Buren, and got a great deal of relief ; and then pain came on
again, and lithotomy was performed one year afterward by the
late Dr. Buck. At the second operation a stone as large as the
original one removed by Dr. Van Buren, of about the size of a
walnut, was removed, and there was no evidence of facets upon
its surface nor in its internal structure, and the explanation of
the presence of the second calculus was found in the fact that
an unusually large bar between the mouths of the ureters divided
the bladder into two parts. Dr. Buck had been much struck by
this condition, found at the time when he operated, and, as the
patient complained about two weeks afterward of some pain, he
anesthetized him again, made another search, and found a small
fragment of a calculus which was lodged in one of the irregu-
larities of the prostatic portion of the urethra.
Dr. A. 0. Post had met with two cases in which there was
contraction of the bladder between two calculi so that the stones
could not come together. His cases occurred in young subjects.
In each case one calculus was near the urethral orifice of the
bladder and the other was far back in the cavity, and there ex-
isted a contraction of the bladder between the two which could
be felt with the finger.
Fistula in Ano. — Dr. Lange directed attention to one way
of treating fistula in ano, namely, cutting the entire canal out
and sewing up the wound. In most cases it was a simple pro-
cedure, and he would be much obliged if the members of the
society would try it. He had adopted it for the first time about
two years before in the case of a woman who had a deep-seated
fistula. In that case he had a complete result, and the patient
recovered in about fourteen days. He had tried it in a limited
number of cases, but he had not succeeded in all; yet he thought
that, with improved technique, the results wTould become bet-
ter. So far, at least, the results were encouraging. Having a
probe in the canal, he dissected all about the probe and cut the
entire fistulous canal away, including some of the tissues sur-
rounding it, and then, with a catgut etage suture, closed the en-
tire wound, and besides inserted several silk sutures around the
whole mass, as after other plastic operations, to relieve tension
and to prevent eventual separation of the lips of the wound in
consequence of too early absorption of the catgut.
The President said he had performed this operation four
times with satisfactory results. In one instance the fistula ran
from the labium to the rectum. His first knowledge of the
operation was obtained from the " Transactions of the Ameri-
can Gynaecological Society," and from a Western surgeon who
reported a number of cases.
Dr. Maukoe had performed the operation twice by scraping
out the fistula, but he had not got good results.
Dr. A. G. Gerster had employed this method in a limited
number of cases, and, as Dr. Lange had stated, with some good
results and with some failures. He thought the method applicable
in cases where the fistula was simple. Where, however, there
were several fistulas crossing each other, as occasionally oc-
curred, and running perhaps in a spiral line around a part of
the circumference of the rectum, and where, after removal of
all the lining of these different canals, a complicated wound re-
mained, the results had not been very satisfactory, the relations
of the wound being such that absolute contact of all the sur-
faces could not bo brought about, and accumulations of secre-
tions with retention in pockets frustrated primary union. But
certainly in simple cases, however deep, up to a certain extent,
the method was a rational one, and it shortened the time of
cure very considerably.
NEW YORK STATE MEDICAL ASSOCIATION.
Second Annual Meeting, held in New York, Tuesday, Wednesday \
Thursday, and Friday, November 17, 18, 19, and 20, 1885.
( Concluded from page 584.)
Wednesday's Proceedings.
A Communication from the American Medical Asso-
ciation, regarding certain proposed uniform State legislation*
was referred to a committee of three, to report to-morrow.
The Discussion on Pneumonia was resumed after certain
other business had been transacted. Dr. Charles G. Stockton
discussed in a brief paper the seventh question propounded by
Dr. Flint, and said he thought the special manner in which the
temperature should be lowered would depend upon the individ-
ual case ; a single antipyretic would not answer in all cases.
He had sometimes used quinine and antipyrine successively in
the same case. Regarding antipyrine, he recommended its use
in from fifteen- to twenty-grain doses once in from eight to
twelve hours. When so used it had never produced any toxic
effects upon the heart, and it had had the desired effect upon
the temperature.
Dr. E. D. Ferguson's experience with antipyrine had been
similar.
Dr. J. G. Orton discussed the eighth question in a brief
paper. He had never seen an unqualified case of relapse of
acute lobar pneumonia during or shortly after the period of
convalescence, but one attack seemed to predispose to subse-
quent ones in the same lobe. He thought pneumonia was a
non-infectious essential fever. He also spoke of complications
and diseases to which pneumonia predisposed.
Dr. F. E. Hyde had in several cases of acute lobar pneu-
monia found evidence at the autopsy that there had been early
and persistent thrombosis as well as embolism of the veins, and
in two cases there had been embolism in the arteries as well.
This condition he thought occurred more frequently than was
supposed, and we could see why remedial measures proved of
no avail, and why death occurred so early in the course of the
disease.
Dr. Shelden and Dr. Ross also discussed the paper.
The Medico-Legal Bearing of Pelvic Injuries in Women.
— Dr. Ely Van de Warker, of Syracuse, read a paper with this
title, in which he said that actions at law to recover damages
for injuries sustained to the pelvic organs in women were be-
coming quite frequent and involved large sums of money ;
they were usually brought against corporations, particularly
cities and villages, and railroad companies. He cited three
616
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Joub.,
illustrative cases, by which it appeared that the facts of the
case, could they be obtained by a thorough medical examina-
tion, were in favor of the defendant, but the verdict was likely
to be in favor of the complainant. Some of the women con-
scientiously but erroneously attributed their symptoms to the
injury sustained, but most of the cases were of a fraudulent
nature. In all, perhaps, there would be found a history of pre-
vious pelvic inflammation, or affections which would fully ac-
count for the symptoms present. The impossibility of a fall of
some nature, which was the usual accident in these cases, pro-
ducing such concussion of the healthy uterus and pelvic organs
as to cause permanent displacement of the womb, or swelling,
pelvic inflammation, and abscess was evident to the physician
but not to the simple juryman, whose sympathies were appealed
to by a suffering woman, while the other party to the action
was a heartless corporation with a supposed unlimited supply
of money.
Dr. Williams, of Boston, and Dr. Alonzo Clark, of New
York, were at this point introduced to the meeting.
An Address on Some of the Relations of Physiology to
the Practice of Medicine was read by Dr. Austin Flint, Jr.,
who said that physiology was the only rational basis of scien-
tific medicine; this was true even if we used the term medicine
in its widest signification, including in it the practice of surgery,
gynaecology, and pathology. A knowledge of anatomy and
physiology was a most important requisite in making a correct
diagnosis. The necessity of a knowledge of physiology was evi-
dent in the study of valvular lesions of the heart, for our ability
to diagnosticate heart lesions depended upon our familiarity
with the functions of the heart and the sounds produced by the
blood current in health. Dr. Flint analyzed the heart-sounds in
different diseased conditions of the heart, in proof of his asser-
tion that a knowledge of physiology was an important element
in scientific medicine. In the same line he cited certain affec-
tions of the digestive tract, Beaumont's observations upon diges-
tion within the stomach through a gastric fistula, the discovery
of vaccination by Jenner, of the circulation of the blood by
Harvey, of the manner of bacteria cultivation by Koch, etc.
Begarding bacteria as causes of disease, the theory offered wide
possibilities, and it was not improbable that methods of preven-
tion and treatment of disease would now be discovered which
would be of the greatest benefit to the human race. Methods
of bacteria cultivation might also prove of value in the study of
the physiology of the fluids and functions of the body. Dr-
Flint referred to an article on the subject of how to treat a fever
as based on physiology, which he published in the " American
Journal of the Medical Sciences" in 1879, and said that fever
meant the rapid use of the heat-producing elements in the econ-
omy, and hence the importance of digestion of heat-producing
foods during a fever to prevent the burning up of the system.
Alcohol in fever was well borne, and temporarily was capable
of taking the place of the elements consumed by hyperpyrexia.
In phthisis with fever hydrocarbons should be given, such as
starch, sugar, and cod-liver oil ; alcohol was well borne by such
patients.
Recto - Labial or Vulvar Fistuke ; their Causes and
Treatment. — Dr. Isaac E. Tayloe read a paper in which he
spoke of the comparative rarity of the condition. It was very
liable to begin with a vulvar abscess, depending upon an inflam-
mation of the vulvar glands, perhaps excited by injury during
coition, masturbation, labor, direct injury, or cold. A small
tumor might exist in the lahium prior to breaking down into an
abscess, perhaps quite movable, and leading to the suspicion of
a displaced ovary. The history of such a case, seen by the
author, was given. The tumor constituting the suspected ovary
broke, and gases and faeces escaped by the small opening.
Huguier's plates were shown in illustration of the subject-mat-
ter of the paper. The pathognomonic symptom of vulvar fistu-
las was the escape of air and thin faeces. The vulvar opening
was usually small — perhaps so small that it could be found with
great difficulty. As to the treatment, he adopted the ligature.
The method was simple and efficient, and, in view of the great
and serious difficulties likely to attend the use of the knife, he
thought it deserved much more general employment. The
elastic ligature was to be preferred.
After reading the paper, Dr. Taylor presented to the society
a form of obstetric extractor given to the association's museum
by Dr. Samuel W. Francis, of Newport. Dr. Taylor also pre-
sented a foetal skull which showed the effects of molding during
extraction from an equally contracted pelvis. The gifts were
accepted with thanks.
Recurring Luxations.— Dr. Edwabd M. Moore then read
a paper on this subject. That luxations were likely to recur he
would not attempt to prove, for it was a well-known fact. Re-
currence of the luxation took place often not as a result of vio-
lence, but of the action of different forces not connected with
violence. Some replacements were maintained with great diffi-
culty. Attention was then called to the tendency of recurrence
of luxations in different joints, and to the manner of preventing
this accident. To prevent it in the case of the clavicle, the elbow
was to be thrown backward and retained in that position by
binding the hand to the side by means of adhesive plaster, or,
what was better, by means of a figure-of-eight bandage ; thus
the scapula would be carried nearer the vertebral column.
Several interesting cases were related in which recurrence of
luxation had taken place in the shoulder joint, and the manner
in which the accident was apt to occur was pointed out. The
reader's views with regard to luxations occurring in this joint
had been made clear by certain experiments which he had per-
formed after removal of the flesh about the shoulder, and bring-
ing forces applied upon the arm and forearm to bear upon the
ligamentous structures. His experiments illustrated incidentally
how it was that, in many cases of sprains, or supposed injury
to ligamentous filaments, the symptoms were as serious as and
more prolonged than in fractures of bone; for, as had been
shown in these instances, the ligament gave way only by taking
with it a portion of the bone to which it was attached. In
luxations at the shoulder, either upon the dorsum of the scapula
or into the axilla, examples would be met with in which main-
tenance of reduction would be found difficult. The manner in
which the luxation took place was by gravity allowing the arm
to fall, especially if at the same time the arm was turned more
or less forcibly outward. Touching upon recurrence of luxation
at the hip joint, the author cited an interesting case which had
come under his observation, and had been reported, with two
others, by Bigelow, in which a soldier acquired the art of dis-
locating and replacing the head of the femur by a certain twist-
ing motion of the body.
The Difference in the Symptoms of Strangulated Oblique
Inguinal Hernia. — Dr. Hyde read a paper with this title, in
which the following were some of the principal points brought
out : 1. In proportion to the length of time an inguinal hernia had
existed would the symptoms and signs of strangulation be mild
and chronic. 2. In a case of loDg-standing inguinal hernia in
which signs of stricture of the bowel were obscure, with no
evidence of total destruction of the canal, it was often not safe
to wait for faecal regurgitation before deciding that strangula-
tion existed. 3. When strangulation occurred at the first pro-
trusion, the symptoms would be found to be more marked. 4.
If hiccough and faecal vomiting had existed from nearly the be-
ginning of the symptoms, no time was to be lost ; kelotomy
should be performed at once. 5. If a swelling existed, with
Nov. 28, 1885.]
PROCEEDINOS OF SOCIETIES.
617
symptoms of obstruction of the bowel, the patient complaining
of severe pain in the abdomen, although of none in the tumor,
but having hiccough, even if there was no marked general disturb-
ance, a fair trial of taxis should be made, and, that failing to
reduce the tumor, kelotomy should not be delayed. This re-
mark was based on an interesting case, the history of which Dr.
Hyde gave in detail. No fsecal vomiting occurred, nor any
pain in the tumor even after taxis, but there was some pain in
the abdomen, with hiccough. Because of the mildness of the
symptoms the consulting physicians delayed the operation more
than twelve days, and, when it was finally performed, the
strangulation was found to have existed within the abdomen.
The patient died. 6. If no strangulated portion was found with-
in the external sac, the finger should be passed internally and
adhesions sought for in the neighborhood of the opening. 7.
Too long a trial of taxis before dividing a stricture should be
guarded against, as it increased the liability to death. 8. After
stercoraceous vomiting had set in, taxis should not be applied,
but kelotomy should be performed at once, although the prog-
nosis was unfavorable. 9. If, after the sac was opened, the
omentum was found smooth, and no intestine could be detected,
the omentum should be unfolded to learn whether it did not
contain a strangulated portion of intestine. It was unfair to
speak of kelotomy as a dangerous operation per se. The danger
attending it was due to the condition of the sac and its contents,
and to taxis and delay in operating.
Dr. J. W. S. Gotjley read some notes on the subject of Dr.
Hyde's paper, in which he stated the following conclusions: 1.
"When doubt arises respecting the existence of strangulation of
the intestine or omentum in a case of incarcerated hernia, it is
the surgeon's duty to give the patient the benefit of the doubt
by at once resorting to the operation of kelotomy. 2. Delay in
relieving the strangulation was often fatal, while kelotomy in a
case in which no strangulation existed was not usually harmful.
3. Medicinal treatment was often delusive, and local applica-
tions, such as opium, tobacco poultices, ice, etc., were in most
cases worse than useless. 4. Persistent taxis was infinitely more
dangerous than kelotomy, and such taxis, even when it was fol-
lowed by reduction, was often the cause of fatal peritonitis. 5.
Another, though rare, effect of violent taxis was the reduction
of the hernia en masse in its state of strangulation, and it was
well known what the result was. 6. As a general rule, two
minutes of gentle taxis, the patient being in a hot bath, would
settle the question as to the possibility of safely reducing the
hernia. 7. Therefore, it might be said with propriety that the
less taxis, the less ice, the less other topical applications, the less
opium, the less general or special meddlesome interference,
which often did serious injury to the intestine, the better the
chances of recovery in the event of kelotomy. This was par-
ticularly the case in femoral hernia. The speaker had abstained
from incising the neck of the sac in femoral hernia, but had
made divulsion by simply insinuating the index-finger through
the free opening made in the sac until it entered the abdominal
cavity, and had had no trouble in effecting reduction of the in-
testine, the object of the procedure being to avoid division of
the obturator artery should it be abnormally situated. He
agreed with Dr. Hyde that kelotomy was not per se a dangerous
operation. Further, if it seemed necessary in a case of inguinal
hernia, after kelotomy he would open the abdominal cavity in
order to relieve the strangulated intestine.
Dr. Variok, of New Jersey, indorsed what the other speak-
ers had said, especially as to the advisability of an early opera-
tion, and the importance of guarding against undue taxis. In
his hospital he always proceeded at once to kelotomy, knowing
that before the patient had reached the hospital taxis had been
carried to a sufficient degree.
The Medicinal and Dietetic Therapeutics of the Com-
mon Forms of Chronic Intestinal Catarrh. — Dr. John S.
Jamison read a paper supplementary to one read last year. It
called out considerable discussion.
A Cursory Review of the Epidemic and Endemic Dis-
eases of Sullivan County during the last Thirty-four
Years was the title of a paper read by Dr. Isaac Puedt.
During the first years of the period, commencing in 1850,
pneumonia and fevers of asthenic type prevailed, in which it
was common to bleed, and to employ cathartics, diuretics, and
a depleting system of treatment, and this course seemed to be
indicated as being followed by the best results. About the be-
ginning of 1854 typhoid fever was heard from in the distance,
and soon reached Sullivan County, and for several years pneu-
monia and other forms of disease took on a typhoid character,
and this period was marked by the fact that in nearly all cases
the asthenic form of disease showed itself ; a depletory course
of treatment was followed by the worst results. Close atten-
tion had to be given to the diet, to encouraging nutrition, and
to checking excessive discharges. About 1860 diphtheria began
to prevail in Delaware County, marched up the Delaware River,
and existed in Sullivan County in the epidemic form for about
five years, being very violent and carrying away many patients.
The odor of persons suffering from the disease was peculiar,
and could be recognized at a great distance from the sick-bed.
In the author's opinion it was a constitutional, not a local affec-
tion, although the local deposit constituting diphtheritic croup
was present. About 1862-63 it was present in the form of
black fever, petechial fever, etc., being in places very malig-
nant. Afterward it again appeared as genuine diphtheria of
the throat. In these cases they applied turpentine and sweet-
oil to the throat at night with benefit. During a part of this
period dysentery prevailed ; first severe, then of mild type.
Scarlet fever was present at intervals of about five years, some-
times of severe, sometimes of mild character. Measles had oc-
curred at different periods, but in general required little treat-
ment. Occasionally diphtheritic cases occurred up to the present
time, but the contagion was generally brought from afar. Ty-
phoid fever had continued to prevail more or less, especially in
the autumn, and typhoid pneumonia during the winter, up to
1881. The spread of typhoid fever up the Hudson and its
tributaries occurred at one period. The highest point was
situated 1,200 feet above the level of the sea. The treatment
consisted chiefly in moving the bowels, particularly with calo-
mel, and then giving quinine.
The discussion which followed was lengthy and of a general
nature, particularly with regard to the treatment of diphtheria.
Commercial Prescriptions.— Dr. Henry Van Zandt, the
author of this paper, was of opinion that physicians should
write their own prescriptions and have their medicines com-
pounded by the apothecary or do the compounding themselves,
and not depend upon the preparations coming from commercial
houses, regarding the exact nature of which they must neces-
sarily be more or less in doubt.
Prophylaxis. — Dr. Isaac de Zodche chose this subject for
a paper, in which he pointed out the advantages of preventive
over curative measures.
Thursday's Proceedings.
Officers for the Ensuing Year.— The nominating commit-
tee had named for president, Dr. E. M. Moore, of Rochester;
for vice-presidents, according to districts, Dr. William Gillis of
the first, Dr. H. Van Zandt of the second, Dr. Frederick E.
Hyde of the third, Dr. Desault Guernsey of the fifth ; for mem-
bers of the council, from different districts, Dr. E. M. Lyon, Dr.
618
PROCEEDINGS
OF SOCIETIES.
[N. Y. Med. Jocb.t
Ira H. Abell, Dr. Thomas Wilson, Dr. F. W. Ross, Dr. S. T.
Clark, and Dr. E. S. F. Arnold. The secretary was instructed
to cast the ballot, which he did in the affirmative, and the presi-
dent declared the gentlemen named elected.
The Demodex Folliculorum as a Cause of Acne.— Dr.
Fell, of Erie County, read a paper in which he described some
rebellious cases of acne which had come under his observation
and bad finally yielded to treatment, the cure, he believed, bid-
ding fair to be permanent. This opinion was founded on his
views regarding the possible or probable aetiology of the dis-
ease. It was true his views were new, but, so far as his own
observation had gone, they were substantiated by facts. In a,
large number of examinations of the contents of the acne tu-
mors, he had always been enabled to find the Demodex follicu-
lorum, usually from six to ten in number. While the presence
of these mites in the skin was not of unusual occurrence, and
had long been known, they had not been regarded as the cause
of acne. Lie had found them in the pus or oil-globule, and not
in the indurated matter. While their presence in small num-
bers might not give rise to apparent disease of the skin, he
thought that when large numbers existed they might stand in
the relation of etiological factors of considerable importance.
The Communication from the American Medical Associ-
ation.— The committee of three, appointed by the president to
report on the communication, recommending that a uniform
law be pressed for passage by the various State Legislatures,
reported that it was inexpedient for the association to enter
upon the discussion of the subject at the present time.
Oxygen in the Treatment of Pneumonia.— Dr. E. G. Jane-
way, by request, made some remarks on this subject before pro-
ceeding to read his address in pathology. According to his ex-
perience, oxygen inhalation in pneumonia was of marked benefit.
It was especially serviceable in incipient cyanosis or just previ-
ous to this symptom ; its use should not be delayed until cyano-
sis had become well marked. If employed at the proper time
it would often be found to tide life over the critical point and
lead the patient on to recovery. Dr. Janeway would also add
to the discussion on pneumonia that he had seen one case in
which the patient had a relapse at the end of a week, as much a
relapse as the relapses of typhoid fever. He said, further, that
he had seen a number of cases in which tuberculosis of the upper
lobe of the lung had 
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